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O.p4 u 1 N• •.0 <br />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.orq/ehd <br /><<F ORa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />a4al <br />I <br />Inspection Date: <br />LL. <br />MA>► �1' ..� ■ .I j1� .�• <br />Facility Address: <br />e I Hi <br />Service Reguest #: <br />a <br />I I U RA4 <br />- <br />r7ho <br />3 t <br />Onsite'Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />anufactur1errr raaiiniing: <br />El <br />12A Ll IL4 <br />jM, <br />Vf l V LSI fes- r `'T <br />SERVICE <br />AkWA g <br />t j VI ■-, a ♦l amILEM/I j'AMR LL�.L <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />MA>► �1' ..� ■ .I j1� .�• <br />❑ electronic Serial #: <br />�- - <br />❑ line test programmed <br />❑ <br />L Leak detector <br />Jodel: <br />mechanical <br />EHD I i!spej� <br />El electronic Serial #: ° <br />El <br />❑ line test programmed <br />minutes <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />AkWA g <br />t j VI ■-, a ♦l amILEM/I j'AMR LL�.L <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />MA>► �1' ..� ■ .I j1� .�• <br />❑ Caldwell System ❑ Other <br />�- - <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />EHD I i!spej� <br />t:❑ <br />Primary piping testing at.- <br />El <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 20 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 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />AkWA g <br />t j VI ■-, a ♦l amILEM/I j'AMR LL�.L <br />!.: �_ i .■ aid /..'.� ��!Jr� j. ..�_.MIX <br />0 1Ws��, FOY AM nXM <br />1� .A A,S. d I MO <br />MA>► �1' ..� ■ .I j1� .�• <br />�- - <br />19411 0WAN yj 7,01111 I <br />NAMMIMM <br />THIS FACILITY IS SUBJECT TO R HOURLY <br />EHD I i!spej� <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />