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Op4U l/y C of <br />?•' ��'•'•OZ SAN JOAOUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.ora/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />�_ V0'—'!:-A <br />/y y /y/ <br />( <br />i <br />Inspection Date: <br />,ry1 <br />Facility Address: <br />i nniakk l ie , � <br />Service Request #: <br />Z�1zCC) 6 q <br />Onsite Service Technician's Name: <br />ICC Service Technicianflnstaller Exp. Date: <br />Manufacturer Training: <br />Yc� Awicko,� <br />_ <br />FF Lavel Li — <br />SERVICE <br />1 0L1"6 1z; <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />/ 8` �, �� -4 J j A i Vi <br />C <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />elm •- e e l � <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Received B : <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 />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />1 0L1"6 1z; <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />/ 8` �, �� -4 J j A i Vi <br />C <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Q 0v-lcte4k - <br />❑ Caldwell System ❑ Other <br />elm •- e e l � <br />Primary piping testing at: <br />❑ <br />psi <br />Received B : <br />minutes <br />Secondary containment testing for: <br />Inj ' i —� UDC(s) Piping <br />3 - ' —8 Str ) UST(s) <br />Testing for the abo�vle�ccompone is are next due by: <br />Note: Please be aware that 2° cont nment 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 />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />1 0L1"6 1z; <br />` QU "fiA001- <br />Q <br />/ 8` �, �� -4 J j A i Vi <br />C <br />V K <br />`�Vou& <br />n `4 e-eA r re v� <br />Q 0v-lcte4k - <br />elm •- e e l � <br />c .c c <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY IME AT EHD'S CURRENT HOURLY RATE. <br />EHD Intor: <br />Received B : <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />