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PgUIN <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />4 F O,ReI� <br />DECEIVED <br />,IUG 0 2 2012 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />1 l��f _ , 1. ` _ <br />Inspection Date: <br />❑ <br />❑ mechanical Model: <br />Facility Address: <br />Service Request #: <br />❑ <br />Leak detector <br />❑ <br />ite Service Technician's Name: <br />ICCervice� Technic ianlinstaller Exp. Date: <br />Manufacturer Training: <br />r <br />❑ line test programmed <br />--iw s—� �� 1:f �: l i i - '�.f� <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />SERVICE <br />1 l��f _ , 1. ` _ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />D line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />--iw s—� �� 1:f �: l i i - '�.f� <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />EHD In or. <br />❑ NA <br />❑ <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 />-This UST facility is APPROVED to operate <br />SERVICE <br />1 l��f _ , 1. ` _ <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />--iw s—� �� 1:f �: l i i - '�.f� <br />minutes <br />�..," -j 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 20 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />EHD In or. <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 />-� T •.-rf`: ! . <br />1 l��f _ , 1. ` _ <br />Gr r v` "�•; /' �✓ s'. Gj '.,-• 1 c.r <br />J <br />✓ ` <br />J+-..1. L'- <br />--iw s—� �� 1:f �: l i i - '�.f� <br />�..," -j I <br />,l' Y <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD In or. <br />Received By: <br />Title: <br />l °' <br />EHD 23-44 , <br />Rev 10/06%10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />