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o.PQ� I N••.c SAN JOAQUIN COUNTY Q: -+ ENVIRONMENTAL HEALTH DEPARTMEN !t u): 1868 East Hazelton Avenue, Stockton, CA 95205-6232 CqC� oRa�P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: oi-,__l Cl to Inspection Date: 1100211:s S�-un3 q - 3. 2019 Facility Address: V Service Request #: ❑ X mechanical Model: CI Q l -D 3010-10 e 1- Onsite Service Technician's Name: NC��,' P,r' r. ICC Servicb Technician/Installer Exp. Date: Manufacturer Training: I 4Rvl EHD Inspn r� a 'm 0,UU-1-P —� - -ICa Vie. 302 SERVICE oi-,__l Cl to ji�Leak detector m'e_c Model: Sq L bQCKD ,LJ ❑ electronic Serial #: n02.j1D(DS+S ❑ line test programmed c:t1A a_L,,_j ko e_ot L kaj- . r Leak detector ❑ X mechanical Model: CI Q l -D 3010-10 e 1- ❑ electronic Serial #: 03100 49 NC��,' P,r' r. ❑ line test programmed ❑ psi EHD Inspn r� a 'm 0,UU-1-P 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 SERVICE oi-,__l Cl to Spill bucket (LJ__Cminimum 5 gallon ,LJ ;9�1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System 'Other jX-G_-j, c:t1A a_L,,_j ko e_ot L kaj- . r Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS e 1- ❑ Caldwell System ❑ Other NC��,' P,r' r. Primary piping testing at: ❑ psi EHD Inspn r� a 'm 0,UU-1-P minutes Received By: CI -Al L--. Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 21 containment components are required 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 � br�t SZA0 Vtr.1lJA4 oi-,__l Cl to d � - O i a_i 3 VVW C0V\0W" -e__3 — a c:t1A a_L,,_j ko e_ot L kaj- . r Gni aive 0 ' oo �,4 d2w-050,41 V1} e 1- NC��,' P,r' r. 1 sSU W i L4 r V400 U S0rV Ld- ha THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. V`lW EHD Inspn r� a 'm 0,UU-1-P . Received By: CI -Al L--. Title: 6W &'.`l - EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT