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PQU IN <br />,o •• ........c <br />'•O� <br />7SAN 41 <br />��' <br />JOACiUIN COUNTY <br />Q. �+ <br />Nl < <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />c��iFOR�`P <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />Facility Address: <br />((�tl <br />�' <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Leak detector <br />Inspection Date: <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />- r <br />Facility Address: <br />((�tl <br />�' <br />Service Request #: 2 <br />455---b <br />1, {' I <br />Il CA <br />J <br />Onsite Service Technician's e: <br />ICP Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />k64L <br />(VI %l, mh <br />—(;aLj- l w - <br />0J 4 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />No- e*ro acOzw <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />ey_ u . p ovicto Aic�z l <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />No- e*ro acOzw <br />Primary piping testing at: <br />❑ <br />psi <br />ey_ u . p ovicto Aic�z l <br />minutes <br />Secondary containment testing for: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <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 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 />Other: see below <br />l T i UST f <br />U acility is NO APPROVED to operate <br />"-S <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />cd U - l5l, <br />No- e*ro acOzw <br />VOA Vw-W4 I <br />�a <br />Own aw <br />ey_ u . p ovicto Aic�z l <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD In tor: <br />e <br />Receiv By: <br />Title: <br />a( wN,G <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />