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Pqu I,N <br />SAN JOAQUIN COUNTY 0 <br />y ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />u .P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />6)a I , QTc <br />Inspection Date: <br />S 1�, 112 - <br />Facility Address: <br />15�� 1Y1 a ' �,T- I /Z <br />Service Request #: <br />-S" 0 65 ZZ w <br />Onsite Service Technician's Name: <br />CL.W ( <br />ICC Service Technician/Installer Exp. Date: <br />17 /2,7((4- <br />Manufacturer Training: <br />Ora', .. ;411 //.� <br />71 <br />❑ line test programmed <br />❑ <br />SERVICE <br />AXhu <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />C' <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECT N 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 />a <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 />AXhu <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />C' <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECT N 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 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 />a <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />AXhu <br />eG° <br />'tiC1511 L/ <br />144 -1iLd <br />C' <br />THIS FACILITY IS SUBJECT TO REINSPECT N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />N <br />Re cei By: <br />Title: <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />