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OPQu Ily C <br />'O� 0 <br />SAN JOAQUIN COUNTY <br />Z —�4 ENVIRONMENTAL HEALTH DEPARTMENT <br />y { 600 East Main Street, Stockton CA 95202-3029 <br />q. :P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />6AS ark -)L, i <br />Inspection Date: <br />1/3111 <br />Facility Address: <br />1 C% C--Q-j1�1C <br />f E-A a A IIA&II,1 <br />Service Request #: <br />9-(`61-)6,/& 1c� <br />Onsite Service Technician's Name: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME EHD'S CURRENT HOURLY RATE. <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />L_L,,eC- sarcit z <br />❑ <br />�7-z�zt -s -Clr WW& <br />:IAII3 s(u�/r <br />SERVICE <br />Leak detector <br />❑ <br />1 mechanical Model: �1°1 C-1) -2 -6J <br />❑ electronic Serial #: j C c? -7111 / <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME EHD'S CURRENT HOURLY RATE. <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 />❑ <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 />This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME EHD'S CURRENT HOURLY RATE. <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 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 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 />li✓ lZ.s� S �! /C' �S%I I IV <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME EHD'S CURRENT HOURLY RATE. <br />EHD Ins <br />ector: /yRecei By: <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />