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°Aq�tN 'c SAN JOAQUIN COUNTY <br />y NVIRONMENTAL HEALTH DEPARTMENT <br />01 <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />q�/FORa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: I 1., jo <br />C1ro srr1-- <br />❑ <br />Facility Address: <br />Service Request #: <br />(.-k-33 Pqe-i1 Q. Ave- <br />� 0 6 5 <br />❑ line test programmed <br />Onsite Service Technician's Name: <br />Icc Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />I <br />- IS <br />asl— LLD <br />IA <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />� 1 <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />THIS FACILITY IS SUBJECT TO REINSPLCTION <br />❑ fail safe Serial #: <br />EHD Inspe r: <br />❑ NA <br />Receive <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 />Drop tube with mechanical overfill at 95% <br />'0'7 -'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 />- -Z.— <br />pill bucket minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell SystemOther aL f>-, <br />g% Spill bucket l/minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System L'Other &-tZ - <br />Primary piping testing at: <br />❑ <br />psi <br />� 1 <br />minutes <br />pla", Q zr- <br />Secondary containment testing for• <br />UDC(s) 7/q I Piping <br />THIS FACILITY IS SUBJECT TO REINSPLCTION <br />11 Sump(s) 7-z UST(s) <br />EHD Inspe r: <br />Receive <br />Testing for the above components are next due by: <br />Title: <br />r,I �p ,al 1-2,5-13 <br />Note: Please be aware that 21 cont inment com onents 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 />AllJro L, <br />J <br />l )n <br />57 . <br />� 1 <br />I - 0 <br />pla", Q zr- <br />la., �-S -lam <br />THIS FACILITY IS SUBJECT TO REINSPLCTION <br />AT ANY VME AT EHD'S tURRENT HOURLY RATE. <br />EHD Inspe r: <br />Receive <br />i <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 A 1 <br />UST SERVICE REQUEST INSPECTION REPORT <br />cb.-P l a4(a - I.1-4wta r- <br />