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OAp.ul^!. C <br />40 <br />Inspection Date: <br />SAN JOAQUIN COUNTY <br />Q. z� <br />N. <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />�A�%FORa`P <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.orci/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />S` <br />Inspection Date: <br />rfrn 00 <br />N � <br />1-16 -N <br />Facility Address: <br />rVIA-5 V,1UQS-k <br />Service Request #: <br />❑ <br />Leak detector <br />❑ <br />Onsite Service Technician's Name: <br />IC Service Tech nician/Insta ler Exp. Date: <br />Manufacturer Training: <br />❑ line test programmed <br />sensor <br />ve,-10-9_ <br />SERVICE <br />S` <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />0 <br />❑ electronic Serial #: <br />rVIA-5 V,1UQS-k <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 />Re I ed <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 />d This UST facility is APPROVED to operate <br />SERVICE <br />S` <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />0 <br />❑ Caldwell System ❑ Other <br />rVIA-5 V,1UQS-k <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 />ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Secondary containment testing for: <br />Re I ed <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 2° containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <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 />eQ x r-5 L <br />S` <br />Q s c! toles 1�- <br />0 <br />G .a <br />rVIA-5 V,1UQS-k <br />'r� <br />Q -' UQLA <br />Corr c <br />THIS FACILITY IS SUBJECT TO REII SPECTIONY <br />ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins ctor: <br />Q,n <br />Re I ed <br />Title: <br />Y't q <br />EHD 23-04 v UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />