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P utN • <br />o • "" c SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />N_ <br />Y. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />q�%FpRa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name:nn <br />Inspection Date: <br />h <br />0Y 7 <br />/ /(-) d-, <br />Facility Address: <br />Service Re uest A. <br />❑ electronic Serial #: <br />if w nv.e-5 . e <br />Onsite Service Technician's Name: <br />ICC Cervice Technic�a Installer Exp. Date: <br />t - <br />Manufacturer Training: <br />l © <br />7� <br />�UbSs : (O slit" <br />SERVICE <br />nQ a <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />oo-� c) �C (A- l; l I S e r Se <br />Q LA-YOw . c e5- �., � n!� <br />❑ electronic Serial #: <br />if w nv.e-5 . e <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />EHD Inspector:R7!iyed <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />�y <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 />Drop tube with mechanical overfill at 95% <br />L❑ <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />This UST facility is APPROVED to operate <br />SERVICE <br />nQ a <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />oo-� c) �C (A- l; l I S e r Se <br />Q LA-YOw . c e5- �., � n!� <br />❑ Caldwell System ❑ Other <br />if w nv.e-5 . e <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />EHD Inspector:R7!iyed <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary c ntainment testing for: <br />.A 6 UDC(s) $71 9 1 Piping <br />Sump(s) UST(s) <br />�y <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 />I Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />W1 L15i � 2t <br />nQ a <br />V I ILvroaqa <br />!Piol aA LA-)%*h�MC-s <br />r o d S _O C Slr <br />4V,,O- .gime- 0 �- 4x,-,) r)! <br />oo-� c) �C (A- l; l I S e r Se <br />Q LA-YOw . c e5- �., � n!� <br />7cy) C -i �b r tkip <br />if w nv.e-5 . e <br />THIS FACILITY_ IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD Inspector:R7!iyed <br />. <br />Title: <br />"l <br />EHD 23-04 <br />Rev 4/30/12 <br />/ UST SERVICE REQUEST INSPECTION REPORT <br />