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o°•'QUIN• .c <br />SAN JOAQUIN COUNTY <br />Q' a ENVIRONMENTAL HEALTH DEPARTMENT <br />N. '{ 600 East Main Street, Stockton, CA 95202-3029 <br />= <br />Telephone: 209 468-3420 Fax: 209 468-3433 Web: www.sugov.org/ehd <br />��FOR <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />/� - ow, 7F011 <br />Inspectio <br />Date: <br />11 <br />Facility Address: <br />5'7k5+ FA <br />Servic <br />0� <br />quest #: <br />[ 111,?; <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />14�� <br />0 q,,% I I <br />VyL [ <br />I 0� I I <br />SERVICE <br />1' <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EFRIS CURRENT HOURLY <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />X 11 <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 />0( This UST facility is APPROVED to operate <br />SERVICE <br />1' <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EFRIS CURRENT HOURLY <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components 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 />X 11 <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />t <br />1' <br />UM <br />0 WAW <br />- -1%inlvi - <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EFRIS CURRENT HOURLY <br />EHD lni�sqor: <br />Receive y: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />