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O Aq U I N• •.0 <br />). �� •.O <br />SAN JOAQUIN COUNTY <br />Q. a ENVIRONMENTAL HEALTH DEPARTMENT <br />N. '. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.org/ehd <br />Cq</F6RN`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />LC)&— <br />Inspection Date: <br />kv oon SAO-56 li <br />❑ mechanical Model: <br />6 1 1-4 <br />Facility Address: <br />085-9 16 i <br />r & t <br />Service Request #: <br />Onsite Service Technician's Name: I <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />6raVilaor, SVI" I 4 V11- <br />-3J-- 16 (G <br />1-1316 <br />SERVICE <br />LC)&— <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />i ✓k e \/ate <br />❑ electronic Serial #: <br />r & t <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />ed By: <br />sensor <br />❑ positive Ishutdown Model: -lC%bl <br />❑ fail safe Serial #: -42 (0 Icy <br />�A <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />I,1 This UST facility is APPROVED to operate <br />SERVICE <br />LC)&— <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />i ✓k e \/ate <br />❑ Caldwell System ❑ Other <br />r & t <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />i, e <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />ed By: <br />minutes i! <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: Please be aware that 2° containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below MV)\JQ,( i fiC)u f � -0 �4 <br />❑ This UST facility is NOT APPROVED to operate <br />tol <br />LC)&— <br />S 5e CD CAA A <br />ek e nh\i0SiO LO C <br />at'd ( U <br />i ✓k e \/ate <br />16, e R <br />r & t <br />o t M 1 <br />ucc 1 <br />c-e,.�► c� <br />cx.�- <br />i, e <br />Cu r e rv� C <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD Inspect <br />1� bC/�J16 <br />ed By: <br />Title- <br />y ctc <br />EHD 23-04... r [����/// 2 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 a -9e 1 - - <br />