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N 1 �' ■ •• Stockton, l�dluunnc. <br /> < SAOHazelon <br /> COUNTY— T 209 468-3420 It F 209 464-0138 1 www•sjgov.orglehd <br /> ,r <br /> Greotness grows here. <br /> UST Installation Inspection Completion Sign-Off Sheet <br /> inspector for sign-off <br /> * he responsibility of the owner,operator,and/or contractorinspections a'nd provided o the insp ctorduration s the US <br /> It is t P tete. <br /> installation. A copy of this form must be available for all inspe <br /> upon completion of each required inspection in order for the inspection to be counted as comp <br /> mcy, vdQ Cvst <br /> Date of Approval Letter: 6119 <br /> SR0086245 Address:4343 Wilson Wa Stockton CA 95205 <br /> **Email notification to ustna sigov.orp to arrange the following inspection appointments. <br /> All appointments must be scheduled at least 48 hours in advance.** <br /> SJC EHD(CUPA) <br /> DATE coMPLETED INSPECTOR SIGNATURE <br /> PRIOR TO BACKFILL KYI St1 nU W <br /> 6a) Inspection of tank vacuum gauge or for brine leaks prior to tank S I31�3 <br /> placement in excavation. n saP 1►'1 <br /> 6b)Verification of tank set, anchorage, appropriate backfill, and appropriate ­65111-3 <br /> additional corrosion protection of tank anchors (turnbuckles, eye bolts, etc.). <br /> Additional corrosion protection is required on all exposed metal prior to <br /> backfill. 2� <br /> anufacturer specifications. <br /> 6c) Primary tank test, in accordance with m <br /> 6d) Primary piping test: Soap test of all piping joints and pduct, <br /> enetrations(pro <br /> vapor recovery, vent, and chase), and pressure testing–hydrostatically at <br /> 150%of design operating pressure or pneumatically at 110%of operating ( (2Q (1q <br /> pressure. If the calculated test pressure is less than 40 psi, 40 psi shall be <br /> used as the test pressure. Testing must be conducted in accordance with <br /> manufacturer specifications and California Code of Regulations (CCR)Title <br /> 23. <br /> 6e) Secondary piping test: Soap test of all piping and penetrations (product, <br /> vapor recovery, vent, and chase), and pressure test, in accordance with 2 12 (2 <br /> manufacturer specifications. <br /> 60 Verification of secondary piping slope for all piping (product, vapor <br /> recovery, vent, and chase) at 1/8 inch per foot or greater,to a containment <br /> sump with an audible and visual alarm. Piping slope must be adequate at the <br /> start of this inspection, with all piping in its final position and ready to be <br /> backfilled without adjustments per the manufacturer's installation instructions. <br /> 6g)Verification of all pipe setbacks, cross-overs, and burial depth, in <br /> accordance with manufacturer specifications, and verification of appropriate <br /> piping backfill. <br /> 6h) Integrity testing of all sumps, in accordance with manufacturer t 12a 91 <br /> specifications. <br /> 6i) Verification of brine type, and witnessing of initial brine addition in all brine- 14 _ -- <br /> filled sumps and/or UDCs. <br /> ❑ ALL PRE-BACKFILL INSPECTIONS HAVE BEEN COMPLETED <br /> SJC EHD(CUPA) <br /> PRIOR TO FIRST FUEL DELIVERY DATE COMPLETED INSPECTOR SIGNATURE <br /> 6j) Verification of leak monitoring communication for all installed vacuum, <br /> pressure, or hydrostatic (VPH) components, including piping, sumps, under <br /> dispenser containment sumps (UDCs), and all chase lines. Communication <br /> at end points of each vacuum zone and each vacuum monitored sump must <br /> be verified independently in operating condition. <br /> Page 1 of 2 <br />