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O.PQ U I N' •.0 <br />SAN JOAQUIN COUNTY <br />WIRONMENTAL HEALTH DEPARTMENT <br />0: <br />1 `:. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <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 am�e:: ) <br />, �N`il � <br />ka © con y- <br />Inspection Date: <br />❑ <br />❑ mechanical Model: <br />a 2 • a` i <br />Facility Address: V <br />-, kt oh, GA 6? 36-& <br />Service equest : <br />SPW64-yaY- <br />Onsite Service Technician's Na <br />- m <br />Leak detector <br />ICC Service Technician/installer Exp. Date: <br />3_a3-�,o15 <br />Manufacturer Training: <br />�Nvo.,ld o/ <br />SERVICE <br />ka © con y- <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />a 2 • a` i <br />❑ electronic Serial #: <br />iwrini-xf <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Oble <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />e O <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 />ka © con y- <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />a 2 • a` i <br />❑ Caldwell System ❑ Other <br />iwrini-xf <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />X42 <br />❑ Caldwell System ❑ Other <br />Oble <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />quel <0o,6 <br />Secondary containment testing for: <br />e O <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />-Testing for the above components are next due by: <br />THIS FACILITY IS SUBJECT TO REINSPECTIO T NY TIME AT <br />Note: Please be aware that 20 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 <br />❑ This UST facility is NOT APPROVED to operate <br />OkSI71e -)10 ve,,- ' /I <br />ka © con y- <br />i oe.& <br />�!,Lk�(�' <br />v � i <br />a 2 • a` i <br />0911 iia f� > <br />iwrini-xf <br />7f�e <br />ove a•,4-& <br />A 9UDE <br />X42 <br />Oble <br />quel <0o,6 <br />5 <br />e O <br />w/_�5/rv/ [i <br />125 6�w <br />THIS FACILITY IS SUBJECT TO REINSPECTIO T NY TIME AT <br />'S CURRENT HOURLY RATE, <br />EHD Ins oor. <br />w a <br />//l %}') qtL <br />Received y: <br />Ti • <br />I Ir <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />