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Pp.U1N <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />I� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />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 />Faci ity Name: <br />Inspection Date: <br />urvwf 0 n SOA <br />1 (0 )- - N <br />Facility Address: <br />Service Request #: <br />joKIa- <br />THIS FACILITY IS SUBJECT TO REINSP CTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />onsite Service Technician's Na <br />brv,avil, <br />ICC SeWi6e Technician/Installer Exp. Date: <br />Manufacturer Training: <br />Gem <br />❑ mechanical Model: <br />SERVICE <br />` c&\) <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSP CTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />Re lived By: <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <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 />SERVICE <br />` c&\) <br />q Spill bucket ❑ minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System Other , /t , 4_ <br />CVvV Spill bucket ❑ minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSP CTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System J>�Other V <br />at <br />Re lived By: <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 APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br />N)AAj i -A1.0 rm oV A0k-- PXk r1ki d'o eu W U'Lf-'�2 r time t' v3y i yam-- k'"'p pro'VO4-�-\ <br />�. & . <br />` c&\) <br />Un 0YUJAACA k5 u)w-) c `lam- l <br />THIS FACILITY IS SUBJECT TO REINSP CTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins r: <br />Re lived By: <br />Tit] . <br />J <br />N <br />fV <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />