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AQUIW SAN .IOAGlU1N COUNTY y I ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: wtrt/w.sigov.orq/ehd \ iFi05 UNDERGROUND STORAGE TANK (UST) PROORANI SERVICE REQUEST INSPECTION REPORT Facility Name: K Inspection Date: 6 Facility Address: BEWce\Ucillxl(2, Lo -t,12 Service Request #: a 0 3�i 5 ❑ mechanical Model: Onsite Service Technician's Name: ICC Service Technician/installer Exp. Date: Manufacturer Training: ❑ Leak detector ❑ SERVICE ,A , -r tS .I l` • Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: IBM# ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: •- • • • ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) ❑ This UST facility is APPROVED to operate a I Or 1-n an P n tnlll.� SERVICE ,A , -r tS .I l` • Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other IBM# Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) V4IR I e9h Piping Sump(s) UST(s) •- • • • T sting for the above components are next due by: 0 O V) 5 w• Note: Please be aware that 2° containment components are 4quired to be tested upon installation. 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate IM -1.n 0 '' % D -O ,A , -r tS .I l` • IBM# Kill, =IWAAR •- • • • _. I AIR ��m�Vkvso- 0 EHD 23-04 \)CLa:) I C 0 � �/ UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12