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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />_ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.crq/ehd <br />4<<F._oRN <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />W"C( III CA L-1 a- S <br />Inspection Date: <br />Facility Address: <br />iSIU V. 0 M i, r►. -fvL n <br />Service Request #: <br />007 7 <br />Onsite Service Technician's Name: <br />)Vk(AW0 5' t) <br />ICC Service Technician/installer Exp. Date: <br />I� Ir 1� <br />Manufacturer Training: <br />�V✓� �fa���1 �-InC�1�1 '!H <br />SERVICE <br />UnkActmt,�,�i N -A A�? -Ck 6 irk • 'i, n , <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT 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 />❑ 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 />PSI This UST facility is APPROVED to operate <br />SERVICE <br />UnkActmt,�,�i N -A A�? -Ck 6 irk • 'i, n , <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 AT 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 />Secondar containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Testing for the above components are next due by: <br />Note: P!ease 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 />rEj] <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />vQ � NI e!��j CA Ck�:� U(\ �� - \ ' .U� / " tit'_ °)l l ,. <br />UnkActmt,�,�i N -A A�? -Ck 6 irk • 'i, n , <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />nrlm <br />Received <br />Title:o <br />EHD 23-04 <br />Rev 4/30/12 <br />/ UST SERVICE REQUEST INSPECTION REPORT <br />