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PV! ty <br />o ••' "' c SAN JOAQUIN COUNTY 40 <br />z� G ENVIRONMENTAL HEALTH DEPARTMENT <br />H. Aft >< 600 East Main Street, Stockton, CA 95202-3029 <br />' • ;P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />9 .ii Oi <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility NamName:L <br />1k <br />461k,' SIL' <br />Inspection Date: <br />3((O f (, <br />, <br />❑ <br />Facility Address: I <br />IS-�C� � i"✓1cc�� Si lir/-�Gj� <br />Service Request #: <br />S�2C�1EI�i�� <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />anufacturer Training: <br />❑ <br />S24Z4W/-"T -flill i <br />rt/�9 X53-9� -7//011 <br />SERVICE <br />tu117LL�- -?" <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 />❑ <br />❑ positive shutdown Model: <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 />t4 This UST facility is APPROVED to operate <br />SERVICE <br />tu117LL�- -?" <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 />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 />Cold start of monitoring panel e,4''0 -4 -e -c h4 -A4 <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />'Sc /AAA" 64,( <br />tu117LL�- -?" <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />fl � <br />Rec <br />Title: <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />