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fl➢"•Ru F�• c <br /> SAN JOAQUIN COUNTY <br /> U)rENVIRONMENTAL HEALTH DEPARTMENT <br /> NJ. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Z. Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.s'gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> San Joaquin General Hospital 1/18/2023 <br /> Facility Address: Service Request#: <br /> 500 Hospital Rd, French Camp CA 95231 SR0085779 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Eric Molgaard 4/6/2023 Pneumercator, 9/14/2024 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> E] ❑ positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 20 containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑Q Other: see below <br /> ❑x This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> On site to witness the following: <br /> -Replacement of the diesel fill and turbine sump sensors <br /> -Installation of the leak detector <br /> NO TESTING WAS CONDUCTED. Please see approval letter dated October 25, 2022 for additional <br /> information and inspections required. Please provide a 48-hour notice to the EHD. <br /> To minimize person to person contact, the EHD is choosing to write the name of the person receiving <br /> the report instead of having them sign. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> Gabriela Garcia-Mejia Emailed to Jesse Escotto Environmental Contact <br /> EHD 23-04 Rev.04/19/12 UST SERVICE REQUEST INSPECTION REPORT <br />