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V I N' <br />C2 �E Y221,1 <br />O.p0. •.0 <br />SAN JOAQUIN COUNTY <br />IT + <br />W <br />• _'. <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />c .. _ •••P <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />9��FOR� <br />❑ <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />C2 �E Y221,1 <br />Inspection Date: <br />❑ <br />❑ mechanical Model: <br />.; —/ /,— / I <br />Fa • • Ad ress: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI A EHD'S CURRENT HOURLY RATE. <br />Service Request #: <br />/L <br />❑ <br />Leak detector <br />1 <br />Onsite Service Technician's Name:C <br />S ice Technician/Installer Exp. Date: <br />IC_—c <br />Manufacturer Training: <br />�, ��e <br />_ <br />\,) /2 - <br />SERVICE <br />C2 �E Y221,1 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI A EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <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 />Overfill prevention (see LG letter 150-1) <br />X-� This UST facility is APPROVED to operate <br />SERVICE <br />C2 �E Y221,1 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI A EHD'S CURRENT HOURLY RATE. <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 />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 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 />)oy,4 d <br />C2 �E Y221,1 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI A EHD'S CURRENT HOURLY RATE. <br />EHD Insp o <br />KVA r <br />Received By: <br />Title: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />