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oPgU I,N••.0 ' <br />SAN JOAQUIN 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 />C9 <br />i. <br />p'fRa\P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />[140VQ4 Cjoon:�� <br />5�0"A <br />1 <br />Facility Address: <br />Service Request #: <br />❑ <br />h <br />❑ <br />Onsite Service Technician's Nam <br />ICC Se7rvic4 Tech nician/I staIler Exp. Date: <br />Manufacturer Training: KW le as <br />( I 1I ( <br />- <br />p - - -( z, <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />I <br />• f I.t�► �� <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />_ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />I <br />• f I.t�► �� <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Re(�� B,: <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />SQcondary containment tes ing for: <br />At -Q311 UDC(s) a Piping <br />Sump(s) UST(s) <br />Testing for the above c mponents are next due by: <br />1A C <br />Note: Please be aware that 2° cont inment 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 />❑ <br />Other: see below <br />This UST facility is NOT APPROVED to operate <br />'% <br />EHD 23-04�nQ 1, UST SERVICE REQQOE%T INSPECTION RET <br />l/ <br />Rev 4/30/12 ' v �1 i � W Q�Qr ) �]�l s ` Ak9- 5 �� ` W , v iI POR <br />fW11AA all! <br />I <br />• f I.t�► �� <br />THIS FACILITY IS SUBJECT TO REINSPECTIONHOURLY <br />EHD lnspecto�Q(,, <br />Re(�� B,: <br />'% <br />EHD 23-04�nQ 1, UST SERVICE REQQOE%T INSPECTION RET <br />l/ <br />Rev 4/30/12 ' v �1 i � W Q�Qr ) �]�l s ` Ak9- 5 �� ` W , v iI POR <br />