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pqU 1,N <br />�o..coG SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />N: !{ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />hi <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />kj4c' <br />0 n <br />Inspection Date: <br />Facility Address: <br />112 C`.o6M <br />CA <br />Service Request #: <br />sl�'Qoroc3aq <br />Onsite Service Techri ' Name: <br />ICC <br />(�Service Technician/installer Exp. Date: <br />C <br />Manufacturer Training: <br />�: vi <br />❑ <br />_ It� <br />_ 1 ' <br />SERVICE <br />D4 AAQ <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 />Received <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 />❑ This UST facility is APPROVED to operate <br />SERVICE <br />D4 AAQ <br />Spill bucket ❑ minimum 5 gallon <br />❑ Incon T <br />Vey► r)0 jGIL3 <br />1 hour hydrostatic -STS <br />❑ Caldwell System �dOther <br />ZkAt,_ \J <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 />Received <br />minutes <br />Title: <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 />`k -4o o g-c:o-v v e, nvi& VWOVN <br />D4 AAQ <br />1 et- <br />Vey► r)0 jGIL3 <br />THIS FACILITY IS SUBJECT TO REINSPECTION <br />ANY TIME T EHD'S CURRENT HOURLY RATE. <br />EHD Ind or: <br />' <br />Received <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />/ UST SERVICE REQUEST INSPECTION REPORT <br />