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OPpUIN�C� �1 Q� . <br />SAN JOAQUIN COUNTY <br />c 2 ENVIRONMENTAL HEALTH DEPARTMENT <br />N. .X 1868 East Hazelton Avenue, Stockton, CA 95205-6232 1 CJ <br />• c .. Pi' Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />9�LF oRc'�� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: I n 1 <br />4,C,C <br />Inspection Date: f <br />jo 1 <br />Facility Address:r <br />�loa <br />Service Request #: <br />s oo T O Oce <br />Onsite Service Technician's me: <br />i <br />ry-el ��,� <br />ICC Service Technician/Installer Exp. Date: <br />313g2�3(yTq)� <br />Manufacturer Training: <br />✓ P 311, j <br />5 " <br />❑ line test programmed <br />❑ <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Q3 <br />❑ electronic Serial #: _ <br />5 " <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />THIS FACILITY IS SOBJEtT <br />- N sensor <br />❑ Model: `c <br />EHD Inspec r: <br />positive shutdown <br />Re ed By: Title: <br />❑ fail safe Seri�I #: D <br />; <br />El NA <br />sensor <br />In positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: 1.412 <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 />his UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Q3 <br />❑ Caldwell System ❑ Other <br />5 " <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />�� <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />THIS FACILITY IS SOBJEtT <br />minutes <br />EHD Inspec r: <br />Secondary containment testing for: <br />Re ed By: Title: <br />UDC(s) Piping i <br />Sump(s) UST(s) <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 />e\ <br />rr�'SeIK <br />o e /o- <br />,�s �r <br />Q3 <br />4- <br />5 " <br />w -- <br />�� <br />r <br />S <br />ra� ris . iciZ,C1�Ntcia.� Orf�C <br />THIS FACILITY IS SOBJEtT <br />TO REINSPECTION AT AINY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspec r: <br />Re ed By: Title: <br />RHD 23-04 1 V J <br />Rev 4/30/12 <br />!r- C_-,-- <br />UST <br />i <br />UST SERVICE REQUEST INSPECTION REPOR <br />