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UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: COUNTY 0 z°°'••.,� SAN JOAQUIN r.' ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Facility Address: Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd Service Request #: J q 2 /,4 UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: a• 4 ei. 'T5`�135 . Inspection Date: T We r iota r -f /o C /V /A -/ 7 — 33 Facility Address: M, Service Request #: J q 2 /,4 Leak detector 4473&35 Onsite Service Technician's Name: 11 1 ICC Service Technicianllnstaller Exp. Date: 3a, Manufacturer Tra'lAP6/ / I 24) rJ erR a , SERVICE Leak detector EIElmechanical Model: ❑ electronic Serial #: M, ❑ line test programmed ❑ Leak detector El❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed - sensor El❑ positive shutdown Model: ❑ fall safe Serial #: ❑ NA ❑ sensor E]❑ positive shutdown Model: ❑ fall safe Serial #: �1 ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fall safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) X This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other M, Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS 0 ❑ Caldwell System ❑ Other Primary piping testing at: ❑ _ psi - minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note. Please be aware that 20 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. �1 Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT iffy, i // / • r /. 0 / . I i iffir-j M, -� iri ,_�r l: . WMA 0 sJ / TO REINSPECTION AT ANY TIME AT EHD'SHOURLY ■ - Rec e - EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT