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o Pqu r N _.C, <br />SAN JOAQUIN COUNTY <br />e' a ENVIRONMENTAL HEALTH DEPARTMENT <br />,.x1 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sagov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: - <br />TZco <br />4-//:5--/',-2 Q 1 <br />Facility Address: <br />Service Re uest #: <br />,30 <br />14 <br />Onsite Service Technician's Name: <br />ICC rvice Technician/Installer Exp. Date: <br />r% <br />Manufac urer Tr�{ming:, f.y <br />Vil ti /Coo r <br />FZA)1Gl rV° t" or 1 <br />? <br />�7 <br />SERVICE <br />Leak detectorp'FlO`t�VolY Roo <br />❑ <br />Elmechanical Mode�Z'�'-84 <br />Vo'e'lectronic Serial #: 31 a I! Z <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />��_ �•f . F� <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ fail safe Serial #: <br />1 4 <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 />© This UST facility is APPROVED to operate <br />SERVICE <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 />-�-,7 "" ' <br />❑ Caldwell System ❑ Other <br />��_ �•f . F� <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />UDC(s) Piping <br />1 4 <br />Sumps) 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. 6 months after.. and every 36 months thereafter. <br />❑ <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 />El 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />o ofeuz e- Vee dL <br />¢ <br />1 r, s Oil 1 <br />-�-,7 "" ' <br />1 0 i <br />��_ �•f . F� <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: (�;� <br />f k rTLC I" <br />1 4 <br />Recei d By: <br />� <br />Title. <br />i <br />El 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />