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o�qu t�••.c <br />.o SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />:< <br />�p 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />�4��:. iiu••�P <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or lehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />tv% <br />'��W , 6Ak <br />-W I (� <br />Insppee`ctionn D1ate: �j <br />Facility Address .. <br />Q'KCk <br />/�I <br />VAI, � <br />Service RequestC#: <br />w V <br />Onsite Service Tech 'ciao' Name: <br />ICC Servic Tec nicianllnstaller Exp. Date: <br />512-�3 <br />Manufacturer Training: <br />-2- T_1 <br />t <br />❑ <br />❑ mechanical Model: <br />w� <br />SERVICE <br />L IL 3 . <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <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 M <br />❑ <br />❑ NA <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 />k This UST facility is APPROVED to operate <br />SERVICE <br />L IL 3 . <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />ceiv d By: <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 T 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 />Other see below <br />❑ This UST facility is NOT APPROVED to operate <br />ON S� 1a rrs 1.r <br />L IL 3 . <br />V <br />�{ <br />/� Laj, <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector <br />ceiv d By: <br />Title: <br />EHD 23-04 , �1 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4130112 <br />