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4LSAN JQAWN COUNTY <br />IRONMENTAL HEALTH DEPARTMEN <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orglehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility ]Name: <br />Inspection Date: <br />Facility Address: t <br />ly(3-01 <br />Service Re�q`uestt##: / <br />6() -)"- <br />�fq�A. Ry', <br />/// <br />U\� <br />aniinstaller Exp- Date: <br />Onsit $etviuqiTbchn1cianiName-1 ICC Service Tech7NW <br />L raNGflng: <br />—ir <br />❑ line test pra rammed <br />f. <br />r s r it. <br />`SERVICE <br />rte,f <br />! <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />/// <br />U\� <br />I] electronic Serial M <br />J <br />❑ line test pra rammed <br />f. <br />r s r it. <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />d <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />sensor <br />❑ positive shutdown Model <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />THIS FACILITY IS SUBJECT TO R INSPEG ION TAN TIME AT EH13'S CURRENT H URLY RATE. <br />❑ NA <br />❑ <br />sensor <br />El <br />❑ positive shutdown Model: <br />r <br />1�.. c•y �_.S <br />❑ fail safe Serial #: <br />❑ NA <br />�s�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 />rte,f <br />! <br />� pill bucket 0eminimum 5 gallon <br />i <br />NO hour hydrostatic ❑ lncon TS -STS <br />/// <br />U\� <br />❑ qal we I S stem ❑Other <br />J <br />La <br />f. <br />r s r it. <br />Spill bucket ❑ minimum 5 gallon <br />LJ <br />1711 hour hydrostatic ❑ Incon TS -STS <br />d <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containmenttesti forf'�r`%I'� <br />i r. <br />UDC(s) =� Pad Piping <br />rlp(s) � NST(s) <br />r.�{1G ��'. � j�'1 <br />ds Ing for the above ComOnenfs are netd <br />THIS FACILITY IS SUBJECT TO R INSPEG ION TAN TIME AT EH13'S CURRENT H URLY RATE. <br />Note_ Please he aware that r wrtteirknanl owponants are regored io be tested upon <br />Installatlon. 6 months after, and every 36 months lherealler. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />r <br />1�.. c•y �_.S <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />of <br />r�7j��.�_--. <br />i <br />t� ..�� . 0,.. •1 (� , <br />/// <br />U\� <br />`"I/`✓� i .. ../ <br />J <br />!` <br />il/ j <br />f. <br />r s r it. <br />I q-70 eu— ' I c '' <br />I <br />d <br />e <br />5' <br />THIS FACILITY IS SUBJECT TO R INSPEG ION TAN TIME AT EH13'S CURRENT H URLY RATE. <br />rHDjn or: <br />�j <br />Recelved�y�. <br />r <br />1�.. c•y �_.S <br />EHD 23-04 U <br />Rev 4!30!12 <br />VIj A <br />UST SERVICE REQUEST INSPECTION REPORT <br />