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°�'a f' <br />?'�°''•° SAN JOAQUIN COUNTY <br />m ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Quick sko <br />Inspection Date: <br />7// ? l7 <br />Facility Address: <br />Service Request #: <br />007d W. Yoser►'ml'fe Af4etq A 95367 <br />SR0077716 <br />Onsite Service Te hnician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />&17,�h; {� IY�J41r <br />1� �g f� <br /><!' PW <br />SERVICE <br />pq <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />v " eckr i' rP laced � � i �� C�M0i►1fr . <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 />❑ <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 />pq <br />IDC Spill bucket ❑ minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS <br />6W I rnsi,cl- 'lle ft P, 11 r,0.11-4►Ne:. dZed 011;e1nal red <br />-STNS <br />v " eckr i' rP laced � � i �� C�M0i►1fr . <br />❑ Caldwell System ;X] Other Cal rp ph pWk( <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 />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 21 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 y tc to�ertaf/'✓I 6fr%100 0*( Df'1 �►' t 10vi "yl L ' lk� �l <br />I <br />gk <br />t <br />s v, aus cc/ !1'► rc l y 0 �6 . Foyncl oeel tei& te r <br />6W I rnsi,cl- 'lle ft P, 11 r,0.11-4►Ne:. dZed 011;e1nal red <br />V�d`ifof AE d delne aIJ h en r 6 <br />v " eckr i' rP laced � � i �� C�M0i►1fr . <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: f� �% j , j _, <br />/!(/SAG//< /� �/l/ <br />Recei ed By: <br />— <br />Title: <br />(� ok �. <-l_ <br />EHD 23-04 <br />Rev 4/30/12 <br />Ow <br />UST SERVICE REQUEST INSPECTION REPORT <br />