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OPaU I!v SAN JOAQUIN COUNTY - Q a ENVIRONMENTAL HEALTH DEPARTMENT N. I 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.slgov.org/ehd q��FpRci� UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: @.Ckl C� �l /VI Inspection Date: Lovk,N 193 G_ o- �vl Facility Address: Service Request #: n�n, C' S Onsite Service Technician's N \f� CZ Lo ICC S rvice Technician/Installer Exp. Date: Manufacturer Training: -(1- \X f 11111 mu +fecKov _ sensor ❑ SERVICE @.Ckl C� �l /VI Leak detector ❑ ❑ mechanical Model: t 45 ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: \f� CZ Lo ❑ electronic Serial #: ❑ ❑ line test programmed _ sensor ❑ ❑ positive shutdown Model: OX ❑ fail safe Serial #: �A — THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT HD'S CURRENT HOURLY RATE. ❑ NA DKTesting sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) ❑ This UST facility is APPROVED to operate P 5-lL SERVICE @.Ckl C� �l /VI Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS t 45 ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other \f� CZ Lo Primary piping testing at: ❑ psi minutes Secondary containment to ting for• OX n UDC(s) — Piping �A — THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT HD'S CURRENT HOURLY RATE. Sump(s) UST(s) DKTesting for the above components are next due by: Title: 110 MC0vA, ( Lca S Note: Please be aware that 2' containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below IThis UST fac'lit is NOT APPROVED to operate J0a ( )bt ; 5 /""J�1 C GC: t. @.Ckl C� �l /VI VI i y�� r)-) ti v) vw1 1- l.0 o5 -- [ A t 45 i r V- \f� CZ Lo r_ laa c04, w !�6 41 hit L'� j pajv 0-,� baA -4 Qj --ft�e k>4 M' -vu OX a "AAJ �A — THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT HD'S CURRENT HOURLY RATE. EHD InspectRecei d By: Title: EHD 23-04Pqx UST SERVICE REQUEST INSPECTION REPORT 1.Rev4/30/12 t �V p �/Vo �/�C/1` ' W — -O �' .i�/