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UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: 'T <br />/' ny (� <br />_ \ �.�t <br />Inspection Date: <br />" 'O <br />SAN JOAQUIN COUNTY <br />,,-- . ,ati <br />�00 <br />I, <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Manufacturer Training: <br />b <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />'P <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />g�1 FpRyx� <br />❑ <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: 'T <br />/' ny (� <br />_ \ �.�t <br />Inspection Date: <br />Facility Address: <br />Service Request #: <br />dnsite Service Technician's N e:! <br />rrC- <br />C! Tech nicianllnstaller Exp, Date: <br />a 0 'ap <br />Manufacturer Training: <br />b <br />SERVICE <br />ow oz,� Lay) �,e rp U_� sv,�� otu se+ - ( -P D e_,Oya-1 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY ME AT EHD'S CURRENT HOURLY RATE. <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 />❑ 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 />P( This UST facility is APPROVED to operate <br />SERVICE <br />ow oz,� Lay) �,e rp U_� sv,�� otu se+ - ( -P D e_,Oya-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 ME AT EHD'S CURRENT HOURLY RATE. <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, B months after, and every 36 months thereafter. <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 />O c--Ctaa) LA� <br />ow oz,� Lay) �,e rp U_� sv,�� otu se+ - ( -P D e_,Oya-1 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY ME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspe 1 <br />ay� n1 <br />R e d By: <br />Title—_ j <br />r e-C_X: <br />END 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4130/12 <br />