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PqU I /y <br />SAN JOAOUIN COUNTY <br />cr s -+ ENVIRONMENTAL HEALTH DEPARTMENT <br />W, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si-ov.org/ehd <br />4��RORN <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Facility Addres <br />N, Tran, ��� - ..�C9 A <br />Service Request #: <br />4-dd .,x(13 <br />site Service Technician's ame: <br />ICC Service Technician/In t Iler Exp. Date: <br />Manufacturer Training: <br />❑ line test programmed <br />❑ <br />SERVICE <br />�t�.�i, Lit- — f`-C�L. ' -9A/IA- j <br />Leak detector <br />❑ <br />❑ mechanical Model: <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 />THIS FACILITY IS SUBJECT TO R INS <br />❑ fail safe Serial #: <br />D Ins ect :er,_ <br />IT/YJAtJ44 <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />Ix This UST facility is APPROVED to operate <br />SERVICE <br />�t�.�i, Lit- — f`-C�L. ' -9A/IA- j <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 />�� <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />THIS FACILITY IS SUBJECT TO R INS <br />UDC(s) Piping <br />D Ins ect :er,_ <br />IT/YJAtJ44 <br />Sump(s) UST(s) <br />❑ <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 />� j s. gip+ Ley ^ /l A r. <br />fr 1' 1 <br />�t�.�i, Lit- — f`-C�L. ' -9A/IA- j <br />�(.C' I d,.4�.� ✓ S479`46 <br />/�A <br />- <br />9 W <br />• l�{/�r�..,. I. 311] <br />�� Y ' N "6,� <br />�� <br />1 y y ry ®W� ) <br />'! <br />THIS FACILITY IS SUBJECT TO R INS <br />A ANY TIME A EHD'S CURRENT HOURLY RATE. <br />D Ins ect :er,_ <br />IT/YJAtJ44 <br />Rived <br />Tit le: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />