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OPCkUIN,•.0 2,• �_,_ :2 AN .IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT U)'. < 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd Cq�%FpR�`P UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: o� AAO-� Inspection Date: :3 ✓ 6 /2 0 � 5 Facility Address: $5 le. �,r.��m o-r-�, Seo ��-�rn'' Service Request #: s X o o-7 / 33 5 Onsite Service Technicia ' -Toe &416 Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: (,v V11Z2�16 4 z %16 SERVICE r eak detector V1 mechanical Model: ❑ ❑ electronic Serial #: I ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) 't This UST facility is APPROVED to operate SERVICE r Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS I ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ 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 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection Other: see below Res ARM ❑ This T facility is NOT APPROVED to operate EHD 23-04 V7 / // V Rev 4/30/12 ,/// UST SERVICE REQUEST INSPECTION REPORT r / 1W in I'll i/ I EHD 23-04 V7 / // V Rev 4/30/12 ,/// UST SERVICE REQUEST INSPECTION REPORT