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ORgU[n!. C <br />q�/FORa` <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME* <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />4re,O <br />'OK <br />Inspection Date: <br />❑ <br />so <br />vt� C <br />Facility Address: I <br />16 ,� <br />R- � ZC C <br />�1 <br />O �✓C J <br />t• -�p <br />Service Request #: <br />IbQw 9_031q Cl <br />Onsite Service Technician's Name: <br />P�.i a m' <br />Leak detector <br />ICC Service Technician/Installer Exp. Date: <br />►a -b -1�- 5�3 I V I� <br />Manufacturer Training: <br />Tif $ --T-6d <br />SERVICE <br />'OK <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />vt� C <br />❑ electronic Serial #: <br />I YD t (C <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 />J9 This UST facility is APPROVED to operate <br />SERVICE <br />'OK <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />vt� C <br />❑ Caldwell System ❑ Other <br />I YD t (C <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: &4 04"0( q I , <br />psi <br />N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />minutes _, a _-� U Q wd -f <br />Receiv <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 />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />'OK <br />24 -p <br />—o e <br />vt� C <br />ej-2— i <br />I YD t (C <br />Q, <br />THIS FACILITY IS SUBJECT TO REINSPECTI <br />N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />s orIts <br />Receiv <br />By: T,jUe^�'� <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />