Laserfiche WebLink
SAN JOAQUIN COUNTY <br />Q I Z? ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />c P i Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si-gov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />k�j lick yew <br />Inspection Date: <br />-7t 6 Ile <br />Facility Address: / - , � ^ <br />4-9,0 W D- <br />� (� ��f <br />m�/� /�[�� <br />Service!Req/west #: <br />% P © 0 - <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />-Z-,�) <br />Manufacturer Training: <br />Gil <br />a tt W1QCT- n o <br />❑ <br />2 t 6 1 I.i <br />oPk) r 1 v/� <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />e D 5 <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />yr <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />THIS FACILITY IS SU JECT TO 0bNSPECf 1pl <br />❑ fail safe Serial #: <br />EHD Inspector: <br />❑ NA <br />XTesting <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 />❑ NA <br />Drop tube with mechanical overfill at 95% <br />e(45 Drop tube with mechanical overfill at 959% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />9 This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket G 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 />❑ Caldwell System ❑ Other <br />e D 5 <br />Primary piping testing at: <br />❑ <br />psi <br />yr <br />minutes <br />I <br />Secondary containment testi n for: <br />THIS FACILITY IS SU JECT TO 0bNSPECf 1pl <br />UDC(s) $ S �l Iping <br />EHD Inspector: <br />Sump(s) UST(s) <br />XTesting <br />for the above components are next due by: <br />&WSPS W WA4 "-�-j <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 />aLxv (/`Cq7 C15 C/o ,ho- ato <br />e D 5 <br />yr <br />6k1:t/, <br />I <br />&9s L4 pe - <br />THIS FACILITY IS SU JECT TO 0bNSPECf 1pl <br />AT ANY TI AT EHD'S C R EN OIJRLY RATE. <br />EHD Inspector: <br />Ige By: <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />