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OP'•au IN••.0 <br />?•+E •P SAN JOAQUIN COUNTY <br />Q a ENVIRONMENTAL HEALTH DEPARTME ' <br />N. 18u6 East Hazelton Avenue, Stockton, CA 9520 6232 <br />Y. <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />(love,'_14areA 0 orn' <br />8 Zc, i <br />Facility Address: <br />Service Request #: <br />553 r --jo <br />SRS & � j'. <br />Onsite Service Technician's NarW <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />;nDs; x uo V3 V-\- <br />YZ -2-01S <br />6ravc : ,S - L <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />i-e_lrok� Jotonlej 0.1 C ', <br />❑ electronic Serial #: <br />-•r6 oud.e.� <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />O t-✓ <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />✓L��C.t��'f <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />EHD Inspector: <br />��i(�%` <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />i-e_lrok� Jotonlej 0.1 C ', <br />❑ Caldwell System ❑ Other <br />-•r6 oud.e.� <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />pr <br />❑ Caldwell System ❑ Other <br />O t-✓ <br />Primary piping testing at., <br />❑ <br />psi <br />✓L��C.t��'f <br />minutes <br />u� f cz/--, CL on "'A Shet <br />Secondary containment testing for: <br />EHD Inspector: <br />��i(�%` <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below • S?englims r l - <br />'V UDC_ <br />❑ This UST facility is NOT APPROVED to operate <br />yon <br />'62o V - ke. ` t- <br />i-e_lrok� Jotonlej 0.1 C ', <br />e <br />-•r6 oud.e.� <br />eo Coy✓ ZO <br />C 0V'ef_S)0Alla1W <br />Ppb - Iii <br />pr <br />O t-✓ <br />l np <br />✓L��C.t��'f <br />IF <br />G2f�t� CE�Etc�c �P <br />u� f cz/--, CL on "'A Shet <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT AN TIMIE AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />��i(�%` <br />Re ived <br />�r� 1► `L' <br />r <br />Title: <br />I 1 ' 4 eP c� <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPO///R/T <br />