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r _ oPo'u IN••.c SAN JOAQUIN COUNTY Q. ENVIRONMENTAL HEALTH DEPARTMENT N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si-ov.org/ehd Cq(%FO'R�\P UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facil* y Name: (� o(e-)�, C;mil Inspection Date: 6 -- �) � �- �! -2 U Facility Address: Service Request #: Ass----) CA- 00co 90 -Q O site Service Technician's Name: chnician/Installer Exp. Date: Manufacturer Training: ❑ ❑ mechanical Model: � ped � SERVICE wackA u k v- e�-t 0-U-46 (ill Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: I "Se,tu:h ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: � ped � ❑ electronic Serial #: ❑ ❑ line test programmed e sensor ❑ ❑ positive shutdown Model: I ❑ fail safe Serial #: THIIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. ❑ NA ❑ 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% !E] Overfill prevention (see LG letter 150-1) This S facilit i 11FRO ED to ope(ate s7�rn � SERVICE wackA u k v- e�-t 0-U-46 (ill Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other I "Se,tu:h Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS (vir, P`r ❑ Caldwell System ❑ Other � ped � Primary piping testing at: ❑ psi e minutes Secondary containment testing for: I UDC(s) Piping THIIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. Sump(s) UST(s) ❑ Testing for the above components are next due by: Title: 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 rj ` Vue ❑ This UST facility is NOT APPROVED to operate 0 UQ- wackA u k v- e�-t 0-U-46 (ill 'ice.! a-OQ- 1ra&czv, CA I "Se,tu:h -(4\v-e a- © y - �-- , t (vir, P`r Ou � ped � a to fo y A e r� _l Z - I THIIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. EHD In ector: ►1 rn C�1�1 Receive By: I " r Title: EHD 23-04e UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12 pa),SQ-fok