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fluty• &.N 4 V/ <br />pt SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Wit, Stockton, CA 95202-96213-5 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siclov.org/ehd <br />4CIcpNN` <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION. REPORT <br />Facility Name: M -,IM 1 e n� oLi" i- n� <br />(Vl <br />Inspection Date: <br />12 6 120 I� <br />&12-6 <br />Facility Address: <br />ServIcice R$O III: <br />Onsite Service Technician's Name: <br />ICC Service Techn c anfinstaller Exp. Date: <br />-2 5Zq Z3 ghlzoW <br />Manufacturer Training: <br />V P- -A mol 3/Z al <br />SERVICE <br />2 <br />Leak detector <br />❑ <br />_ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />_ <br />❑ mechanical Model: <br />E spa <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test ro rammed <br />a ensor y( a <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />El❑ <br />positive shutdown Madel: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />El❑ <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 />SERVICE <br />2 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />_ Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIIS FACILITY IS SUBJECT <br />❑ Caldwell System ❑ Other <br />E spa <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 W aware that 2c containment components are required to be tested upon <br />matellation, 8 months after, and every 38 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />J <br />2 <br />Cc ntcz <br />2 <br />U <br />r o. /-4-Hfr d < S -(4, tki F0 <br />THIIS FACILITY IS SUBJECT <br />TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />E spa <br />Rq�ived Bh. %/� <br />C/�uC <br />TIOLV� �( ^ <br />(/ // '" I' �/pte: �ad rn� 2ctt Sill rP¢u:re,r <br />EHD 23-04 j <br />nysyyf�.F ��� _ j, US SER�GICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 , <br />