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O.P� U I N' •.0 <br />?' y ' 9 SAN JOAQUIN COUNTY <br />y+ ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />CqC <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.org/ehd ! o--R��P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />ehekj-_L <br />tom- <br />Leak detector <br />❑ mechanical <br />Facility Address: <br />Servi a Req est #: <br />g electronic <br />Serial #:?, Z:-3 <br />Onsite Service Technician's Na e: <br />CC Service Technician/Installer Exp. Date: <br />Manufacturer aining: <br />ai-X <br />S Ii It3 <br />�JL I <br />This UST facility is APPROVED to operate <br />SERVICE <br />SERVICE <br />ehekj-_L <br />tom- <br />Leak detector <br />❑ mechanical <br />Model:,?.R. q414 <br />•�d <br />g electronic <br />Serial #:?, Z:-3 <br />Spill bucket ❑ minimum 5 gallon <br />❑ line test programmed <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Leak detector <br />❑ Caldwell System ❑ Other <br />❑ <br />❑ mechanical <br />Model: <br />psi <br />❑ electronic <br />Serial #: <br />❑ line test programmed <br />cXiiekjensor <br />5; t^j <br />Sump(s) UST(s) <br />R positive shutdown <br />Model: 7� <br />❑ fail safe <br />Serial #: <br />installation, 6 months after, and every 36 months thereafter. <br />❑ NA <br />Cold start of monitoring panel <br />❑ <br />ve sensorrj <br />�— I�Uf <br />Other: see below <br />positive shutdown <br />Model: <br />❑ fail safe <br />Serial #:11 <br />NA <br />is -2 iice— sensor <br />5elopositive shutdown <br />Model UIZ 33ww -4 64 <br />❑ fail safe <br />Serial #: dJr1 <br />❑ NA <br />❑ <br />Drop tube with <br />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 />.4L-1 <br />-- <br />Spill bucket minimum 5 gallon <br />� 7 c LA-I,-- <br />A-I,-THIS <br />1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />EHD pec o . <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 />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: Please be aware that 21 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 <br />❑ This UST facility is NOT APPROVED to operate <br />a— oL-lix—L U)2— -5 3 V6 Y— C-" LA 4- <br />.4L-1 <br />-- <br />� 7 c LA-I,-- <br />A-I,-THIS <br />THISFACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD pec o . <br />t I I n <br />Receivd By: <br />Title: <br />E H D 234 / <br />Rev 10/06MO <br />V \ _— UST SERVICE REQUEST INSPECTION REPORT <br />