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AqulN. <br />�o.j,coG SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />. 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or /q ehd <br />��%FORa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />9 <br />� <br />Inspection <br />D <br />ate: <br />it <br />El electronic Serial #: <br />Facility Addr s: <br />r <br />S rvice R quest #: <br />60 <br />C nu+c Avt -- <br />043 k�- <br />site S rvice T%e�c�h�t ion,'{s <br />ame: <br />ICC Service Technicia n <br />Iler Ex . Date: <br />M nufacturer Trainin <br />a/ W i V, (JV <br />❑ fail safe Serial #: <br />❑ NA <br />All SERVICE <br />I' L <br />Leak detector <br />%mechanical Model: 14�1 ZOO <br />❑ <br />El electronic Serial #: <br />❑ line test programmed <br />Leak detector Lh—'--W 7 <br />mechanical Model: <br />❑ <br />❑ electronic Serial #: - <br />Ins ct <br />❑ line test programmed <br />Receiv I <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />i Ify" - <br />SERVICE <br />I' L <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 />Ins ct <br />❑ Caldwell System ❑ Other <br />Receiv I <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 />- ' r �, .. <br />EHD 3-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />I' L <br />,] L/f� <br />r 1%JV vA� <br />` <br />THI FACILITY IS SUBJECT TO REINSPECTION ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Ins ct <br />r <br />Receiv I <br />Title <br />- ' r �, .. <br />EHD 3-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />