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QU 11V <br />oA SAN JOAQUIN COUNTY <br />1• � •.OG <br />e. ENVIRONMENTAL HEALTH DEPARTMENT <br />t < 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />-ten <br />Inspection Date: <br />i4-kq - �v <br />Facilit Address: <br />CA <br />Service Request #: <br />site Service Technician's Name: <br />ICC Service Technician/In taller Exp. Date: <br />Manufacturer Training: 1, - �(� G <br />no ScIan e- <br />i� 1.�- � <br />_ <br />fi1- Io-� _Is, > - 5 � -1 <br />SERVICE <br />[1 s ` PL Uas <br />meui <br />Leak detector <br />' <br />Y mechanical Model: <br />❑ electronic Serial #: <br />04 ❑ line test programmed <br />� c k a,<a;,- <br />111 Leak detector <br />l <br />i Kmechanical Model: <br />up-- <br />❑ electronic Serial #: <br />� eOct <br />❑ line test programmed <br />THIS FACILI Y IS SUBJECT TO REINSPECTIO AT ANY TIM AT EHD'S CURRENT <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Received <br />❑ fail safe Serial #: <br />Title", <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <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 LG letter 150-1) <br />This UST facility is APPROVED tQQ operate <br />N7 clad -tch Q,4/aI <br />I„ <br />iA.Vn '%u +&--i[:1_17 <br />SERVICE <br />[1 s ` PL Uas <br />meui <br />} Spill bucket .minimum 5 gallon <br />1 hour hydrostatic ❑ Incon TS -STS <br />17 <br />❑ Caldwell ys emsi.Other . uT <br />ko re- OL 1 GL. -1 l o 04 <br />1 Spill bucket)4 minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />� c k a,<a;,- <br />❑ Caldwe I st 11 Other dIW O <br />�e�d o,- <br />Primary piping testing at: <br />up-- <br />psi U� <br />� eOct <br />minutes <br />THIS FACILI Y IS SUBJECT TO REINSPECTIO AT ANY TIM AT EHD'S CURRENT <br />Secondar,Y containment testin,9 for' <br />4 3/ UDC(s) Piping <br />EHD Inspector: <br />!, <br />t%ll ISW Sump(s) UST(s) <br />V- q1 <br />Received <br />Te ting the above components are next by: <br />ROO u IDS n LDLqatL <br />Title", <br />Note Please be aware that 2° contatiment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />e e <br />[1 s ` PL Uas <br />meui <br />CL( -P-.- <br />_5 <br />ko re- OL 1 GL. -1 l o 04 <br />-fie v� ear <br />� c k a,<a;,- <br />�e�d o,- <br />up-- <br />.[ q'i I <br />� eOct <br />THIS FACILI Y IS SUBJECT TO REINSPECTIO AT ANY TIM AT EHD'S CURRENT <br />HOURLY RATE. <br />EHD Inspector: <br />!, <br />tat a ft)a <br />Received <br />/\/\, <br />Title", <br />EHD 23-04 <br />Rev 4/30/12 <br />F-, 9_�, I <br />*,4_ <br />UST SERVICE REQUEST INSPECTION REPORT <br />