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O.P�u CLW1y. <br />�� SAN JOAQUIN COUNTY <br />2: r -rri—. •G <br />Q' "4VIRONMENTAL HEALTH DEPARTMENT <br />N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />'• P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />)i6 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fac Hit Name: <br />- <br />Inspection Date: <br />a ►_ <br />Facility Address: <br />-f3a(3 /VV <br />Service Request #: <br />T, 004 q <br />Onsite Service Technician's Name: <br />r�� ,,� rn� <br />ICC ServiQb Tech niciaMnstaIler Exp. Date: <br />- IS <br />Manufacturer Training: <br />S- (4-,),0I T. <br />SERVICE <br />v to tA <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />;i c ,� d�to��a' CJAAO�h0V) r �, <br />❑ electronic Serial #: <br />Q CWW <br />❑ line test programmed <br />EHD Inspector: <br />a �CL%) �,-3wva\� <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />Drop tube with mechanical overfill at 95% <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LIS letter 150-1) <br />NThis LAST facility is_APPROVED to pperate <br />m►} <br />SERVICE <br />v to tA <br />Spill bucket $minimum 5 gallon <br />0 l cz pwc+—s --, <br />1 hour hydrostatic ❑ Incon TT <br />;i c ,� d�to��a' CJAAO�h0V) r �, <br />❑ Caldwell System ❑ Other <br />Q CWW <br />Spill bucket minimum 5 gallon <br />1 hour hydrostatic ❑ Incon TS -STS <br />EHD Inspector: <br />a �CL%) �,-3wva\� <br />❑ Caldwell System ❑ Other <br />a -I n <br />Title: <br />�C /•• UjC i.44 <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, 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 />J <br />v to tA <br />0 l cz pwc+—s --, <br />;i c ,� d�to��a' CJAAO�h0V) r �, <br />Q CWW <br />NISIFAd—ILITI IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />a �CL%) �,-3wva\� <br />Received By:_ <br />SGtl.YY1 C <br />Title: <br />�C /•• UjC i.44 <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 ,n <br />V <br />