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O.P'4 u I N •.0 <br />�.• .r,�it •.O <br />2; ___; _ •.2 AN JOAOUIN 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 />C9C%FORN`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />�� <br />Inspection Date: <br />Loin <br />-e� CA `3 <br />5 a�-zoo <br />Facility Address: U <br />I <br />Service Request #: <br />115-5 `!A - 0_6 , c 0,0 o CA - <br />Leak detector <br />Onsite Service Technician's Name. <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: :` — <br />I -ti COLA <br />- - 2O 1 <br />o - 4 b j b' 1 <br />SERVICE <br />�� <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />X 55 .A �o w, Ck <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ fail safe Serial #: <br />❑ NA <br />KTesting <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 />�� <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 />AP I S S0* - -air -moo -2 <br />❑ Caldwell System ❑ Other <br />X 55 .A �o w, Ck <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Second ry containment to ting f_JAor <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />J,- UDC(s) Piping <br />Sump(s) _ UST(s) <br />KTesting <br />for the above components are next due by: <br />41�ffi� <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 />T Is UST facility is NOT APPROVED to oper to <br />Aad <br />0V1si <br />�� <br />t Y i t -ie�t- 5 <br />lknpff-) <br />Ct��d ILAUe ezi <br />AP I S S0* - -air -moo -2 <br />NQS_ V <br />X 55 .A �o w, Ck <br />V-UYVA <br />LC�AQ60 <br />n,)Iy) . <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins or: <br />Rec ive By: <br />Title- <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />