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O Pq � I N• •.0 <br />SAN JOAQUIN COUNTY <br />Q. a ENVIRONMENTAL HEALTH DEPARTMENT <br />N. 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 />WV' <br />Inspection Date: <br />Leak detector <br />❑ <br />Facility Address: <br />Service Request #: <br />165,2) 0-axtic'A <br />Onsite Service Technicia Name: <br />ICC Service Technician/Installer ExR Date: <br />Manufacturer Training: <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />v c C,- =; <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />►+s w� o/ <br />❑ line test programmed <br />ck <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />W ks <br />e©V1nU� -bkAX,4 <br />❑ fail safe Serial #: <br />Qote'. U.11Cs <br />e"t <br />❑ NA <br />❑ <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 />rE71r0y7eill <br />prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />v c C,- =; <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 />Primark piping testing at: <br />►+s w� o/ <br />�5psi <br />ck <br />i minutes G -,,J `pP SL.pp (a - <br />C( <br />Secondary containment testing for: <br />W ks <br />e©V1nU� -bkAX,4 <br />UDC(s) Piping <br />Qote'. U.11Cs <br />e"t <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />1 -20 ILL 0.=t I �1/1' <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 />Thls UST facility is NOT APPROVED to operate <br />dQsc /T(vzc � SI d Q ULix <br />' r <br />V -IO b <br />v c C,- =; <br />►+s w� o/ <br />, P-6 • �s>� e <br />ck <br />0-U b;, N <br />C( <br />n 0 <br />W ks <br />e©V1nU� -bkAX,4 <br />ab ru$IQIV I, t m• <br />O- - %e a <br />Qote'. U.11Cs <br />e"t <br />&�Oa . <br />is SCOA acu'a 2.10 <br />y- JP- <br />1 -20 ILL 0.=t I �1/1' <br />HIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspec or. <br />IDL a*f) <br />n <br />Re eived By: <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />