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PQUtN <br />�o,E co SAN JOAQUIN COUNTY <br />Oa:..��IIII -� ENVIRONMENTAL HEALTH DEPARTMEN <br />IP <br />W: <br />l { 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.so-gov.orq/ehd <br />Q�/FORa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name����'v' ® /91 <br />� � � I / <br />In�pecti�at <br />Facilit,y Address: <br />1-7661 1/-\) a 1�*OWN <br />LN�+ LP <br />Service Request#: <br />Onsite Service Technician's Name: <br />IA 4 06 Wim, <br />ICC Service Technician/In aller Exp. Date: <br />`b-s-1skl;�► <br />Manufacturer Training: <br />�-1001i S X1-13 <br />SERVICE <br />f <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />, XIV �'� <br />❑ electronic Serial #: <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 />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 />f <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />, XIV �'� <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 testin tfor: <br />UDC(s) 791 Piping <br />Sump(s) UST(s) <br />Testi for the above components are next due by: <br />t, I <br />Note: lease 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 />01WIXTOXIIIII WON <br />Rwfl-10 WW <br />f <br />VA <br />r� -�..!,., <br />, XIV �'� <br />-.ON <br />"WRTMIN-OF <br />EHD 23-04 I , UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 J <br />