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OP''0.UIN'•.0 <br />).• �.,��• •.O <br />_:• ��__ :i _ AN JOAOUIN COUNTY . <br />Q. -+ ENVIRONMENTAL HEALTH DEPARTMENT <br />N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />Cq�/FpRN`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />a�v (oo <br />❑ mechanical Model: <br />Facility Address: \ <br />it <br />u Rnt <br />I <br />Service Request #: <br />ovb�'5b:�) <br />Onsite Service Technician' Name: <br />(Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />WC6,44% :0 0-m-4 <br />1 1- -1 1 -- <br />NJ -t;Lo- VR -3 -a�-1 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />81+ <br />❑ electronic Serial #: <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />a x,00 aka <br />❑ line test programmed <br />is <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Qf7� a� <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />F� I ' "- Uig <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />,ger, <br />❑ NA <br />mC r <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />Drop tube with mechanical overfill at 95% <br />PGZl LtlL Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />D611 -This UST facility is APPROVED to operate <br />SERVICE <br />Q Spill bucket minimum 5 gallon <br />1 hour hydrostatic ❑ Incon TS <br />` ��� <br />-STS <br />81+ <br />Caldwell System XPther C"LIiN \/L-&\+ <br />d, L Spill bucket � ,minimum 5 gallon <br />1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System Other dtq� v, UQkv <br />y <br />Primary piping testing at: <br />❑ <br />psi <br />a x,00 aka <br />minutes <br />is <br />Secondary containment testing for: <br />UDC(s) Piping <br />Qf7� a� <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />F� I ' "- Uig <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 />,ger, <br />Other: see below iz-'�A <br />❑ This UST facility is NOT APPROVED to operate <br />lQ <br />` ��� <br />r cL rte_ S� <br />81+ <br />`Q ek <br />')o <br />�o <br />y <br />_ <br />tl ; - _ <br />N r <br />a x,00 aka <br />e.� 1C z <br />is <br />Sjb ► 3 - <br />/ " �q 'I- <br />C11 <br />Qf7� a� <br />kerxe 15er <br />?�" <br />t ((g'� - �- <br />F� I ' "- Uig <br />�-Q ma.A inf <br />u1,�t <br />!. , is r 1,xu nj at <br />i C -lq- `C%L <br />► � nye <br />,ger, <br />�c� <br />mC r <br /><s q Q a2 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENt HO RI Y TE. <br />EHD In tor: <br />Rec edtBy�' - <br />TiXi� <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />