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UHEVKON 2216 GUU 31tu p.'L <br />l e'o 26 770 <br />MAY 16 2014 <br />�� • SAN JOAQUIN COUNTY � <br />r-cFr . <br />ENN IPONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone; (209) 4k 8-3420 Fax: (209) 468-3433 Web: www.sigov.or //eehd <br />UNDI RGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />I <br />Facllit me: <br />SERVICE <br />Inspe lon Date. <br />❑ <br />Leak detector <br />Fac 1i Iddr-egsSer-v1A <br />-f",( <br />mechanical Model:._. <br />.,.A - <br />I U -W <br />Re%q�u�e *: <br />A S.A <br />A <br />❑ Caldwell System ❑ Other <br />❑ line test programmed <br />Ons i e 1 s <br />me: <br />t ryice TechrticianlJnatal{erp`. - Tte: <br />Ma ufacturer Tr fining: <br />{c�e�(Techntct�an <br />mechanical Model: <br />Secondary containment testing for. <br />110. <br />M1 <br />4p' ' -is UST facility+is APPROVED too erste <br />SERVICE <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />Leak detector <br />❑11 <br />mechanical Model:._. <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />11 electronic Serial #: <br />❑ Caldwell System ❑ Other <br />❑ line test programmed <br />Primary piping testing at <br />] <br />Leak detector <br />— minutes <br />mechanical Model: <br />Secondary containment testing for. <br />electronic Serial #: <br />Sump(s) UST(s) <br />❑ line test programmed <br />Testing for the above components are next due by: <br />'sensor <br />positive shutdown Model: U?Stl; <br />❑ <br />Cold start of monitoring panel <br />fail safe Serial* <br />Corrosion protection <br />❑ <br />A <br />sensor <br />Elipositive <br />shutdown Model: <br />fail safe Serial #: <br />NA <br />sensor <br />positive shutdown Model: <br />fail safe Serial #: <br />11 NA <br />❑ <br />Drop tube with mechanical over <br />ill at 95% <br />❑ <br />Drop tube with mechanical over ill at 95% <br />❑ <br />Overfill -prevention (see LG letter 150-1 <br />4p' ' -is UST facility+is APPROVED too erste <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic O Incon TS -STS <br />O Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TOR INSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Primary piping testing at <br />] <br />psi <br />— minutes <br />Secondary containment testing for. <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note. Ploeae be aware pal r ccnmhment cumpanema are roqubed 1c be tested upon <br />installation. 6 months atter. and every 36 mcrths Vwmaier. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23_c4 UST SERVICE REQUEST INSPECTION REPORT <br />ReV 413x'12 i <br />i <br />THIS FACILITY IS SUBJECT TOR INSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />E' .til pecior. • 4 ,; 4 /' <br />Ijecafved By. <br />r1Ua: <br />EHD 23_c4 UST SERVICE REQUEST INSPECTION REPORT <br />ReV 413x'12 i <br />