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opa.0 I N...c <br />�. _ E•f .o <br />__• ^��_ .� SAN JOAOUIN COUNTY <br />Q. ENVIRONMENTAL HEALTH DEPARTMENT <br />Ni 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />"9C%FpR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility N�am�ye•.:: A <br />veb yli�l C�� <br />Inspection Date: <br />Leak detector <br />❑ <br />Facility Address: IService <br />I bW:P� <br />Request #: <br />7-zv <br />'< <br />Onsite Service Technician' Name: <br />ICC S rvice Technician/Installer Exp. Date: <br />Manufacturer Training: <br />SERVICE <br />CoC� LA- VY',12-� <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPE&ION AT ANY TIME A HD'S CURRE T H R Y RATE. <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Title:' <br />T" b <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 />CoC� LA- VY',12-� <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 />rale Ate, CU I ll' a (0, <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPE&ION AT ANY TIME A HD'S CURRE T H R Y RATE. <br />Primary piping testing at: <br />❑ <br />psi <br />Title:' <br />T" b <br />minutes <br />on containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Testing for the above com onents 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 />❑ <br />Other: see below <br />L� This UST facility.is NOT APPROVED to Qperate <br />V UIN ,I <br />e 15e&a� (Lo-,tce) <br />CoC� LA- VY',12-� <br />rale Ate, CU I ll' a (0, <br />,i- l <br />THIS FACILITY IS SUBJECT TO REINSPE&ION AT ANY TIME A HD'S CURRE T H R Y RATE. <br />EHD Inspector:Rece <br />d ky: <br />Title:' <br />T" b <br />V <br />h <br />EHD 23-04UST SERVICE REQUEST INSPECTION REPORT <br />.r�� <br />Rev 4/30/12 ?C18 <br />e— I " Z' <br />