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o0, <br />4UtN c SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Nho <br />?. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*gov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />�r <br />Inspection Date: <br />^ <br />R <br />-�o- 201 <br />Fa pity Address: UService <br />Request #: <br />Ks L t� c <br />Slk0(o b, g9_,23� <br />Onsite Service Technician's N e: <br />ICC Ser ice Technician/Installer Exp. Date: <br />Manufacturer Training: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />4L_Z (erj iiA��Lo <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />4W't)iC <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />EHD In ctor: <br />QA'LO MaA �LQ <br />❑ fail safe Serial #: <br />XTest' <br />❑ NA <br />Title <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />4L_Z (erj iiA��Lo <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />• <br />- X 4 <br />❑ Caldwell System ❑ Other <br />4W't)iC <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Se o dary ainment testing for: <br />EHD In ctor: <br />QA'LO MaA �LQ <br />aGoUDC(s) Piping <br />XTest' <br />Sump(s) UST(s) <br />Title <br />g for the above components are next due by: <br />� CA— <br />Note: Please be aware that 2° contain ant 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 />T . UST facility is NNOT APPROVED fo operate <br />es <br />EHD 23-04K. e � -}(�� � �j1 (,�,(� 1L� �� �`o c�T J ��{ , �, UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 `yj,�,� - ` ^ 'tL� l V-LWx u L/� In v I \ { (ed <br />A�Qk <br />4L_Z (erj iiA��Lo <br />'t, 2_�t <br />112 <br />< <br />L.Q t � ' <br />-, LQ <br />• <br />- X 4 <br />4W't)iC <br />(a_uck acoo <br />cuC <br />rrou-) <br />THIS FACILITY S SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD In ctor: <br />QA'LO MaA �LQ <br />R <br />ceive By: <br />--, 14�� <br />Title <br />EHD 23-04K. e � -}(�� � �j1 (,�,(� 1L� �� �`o c�T J ��{ , �, UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 `yj,�,� - ` ^ 'tL� l V-LWx u L/� In v I \ { (ed <br />