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OPp•U•IN'•.0 <br />>• � •o SAN JOAQUIN COUNTY <br />tNVIRONMENTAL HEALTH DEPARTMENT <br />;2 <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />4�/PORN <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />—b 6j MCS v-4 <br />GCAI� s 011 <br />Inspection Date: <br />0(-+ --. I z� 2 <br />Facility Address: <br />2l$5 <br />Service Request #: <br />Onsite Service Technician's Na <br />e: <br />ICC Service Technician/Installer Exp. Date: <br />�o q �/i2 /Zo <br />Manufacturer Training: <br />VA11L �l /ZoI <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />Leak detector , <br />mechanical Model:IIMD Za7o <br />❑ <br />yK <br />❑ electronic Serial #: it 6 <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <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 />❑ Caldwell System ❑ Other <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 20 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 />a d <br />IS FACIJIV IS SUBJ CT TO EINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins tor: 11V Received B Title: <br />f � P <br />EHD 3-042 <br />Rev 4//30/1 V <br />Li�_ <br />UST SERVICE REQUEST INSPECTION REPORT <br />