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rf� <br /> �. oSAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT <br /> � j�f l 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> cP. Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sioov.org/ehd <br /> 4(t FOM1� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Arco -AM Pk x- 31-I <br /> Facility Address: Service Request#: <br /> 4 1 D vel CA SRQ015q0lI <br /> Onsite Service Technician's Name: ICC Service Technicianfinstaller Exp.Date: Manufacturer Training: <br /> e �C _5_ uk - <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ El mechanical Model: ❑ ❑ 1 hour hydrostatic L1 Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> ❑ ❑fail safe Serial #: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑fall safe Serial #: Note Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Other: see below Vl <br /> ❑ This UST facility is APPROVED to operate ElThis UST facilityQ-V is N T APPROVED to�ofYbtoperateQL Oe-(ane <br /> Ovs't +,e 'Lw;, r-Lle IN - k1 Skku-,- couare$e ob eL-- <br /> a lus e RsI;.>vvo4 L- 31 <br /> Ct" SW o r -{4e&ded aud &Qryed " f-v\nc-Q N <br /> V. O <br /> "V\5 Awkk PA 4eas 64AQQ C Q M- <br /> i AA, tcueallled <br /> J�o U,LS Q <br /> e gctjsl ' <br /> THIS FACILITY IS SUBJECT T REINSP CTION AT XNY TIME AT EHD'§ CURFAENY HOURLY RATE. <br /> EHD Insp Receiv ByY7 Titl <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />