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?• ��' o <br />SAN JOAQUIN COUNTY <br />G <br />•2 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Technician's Name: <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or /q ehd <br />�q�iFOR�`P <br />Lsi.te.Service <br />i t <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />A -One C�y /Vod <br />Inspect* Din Drte: <br />I g /C) <br />Facility Address: <br />C-:�?7y W. 61?tl-# Z ��� �� 7r?.r✓ <br />Service Request #: <br />Technician's Name: <br />ICCiServiceTechntcia Installer Exp. Date: <br />Manufacturer Training: <br />Lsi.te.Service <br />i t <br />Z-1 <br />'m W c1 1. j <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY F -AT E D'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />'Deceive By: - <br />❑ line test programmed <br />❑ <br />Leak detector titin G _ <br />mechanical Model P1= LD 2p00 <br />❑ electronic Serial #: - <br />❑ <br />❑ line test programmed <br />Leak detector liz 21)SIA c' <br />mechanical Model: �(NfL I hD7i <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <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 />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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY F -AT E D'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />'Deceive By: - <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <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 />s✓ ? -� <br />�IA011sy/yy <br />"k <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY F -AT E D'S CURRENT HOURLY RATE. <br />EHD Inspect — , <br />'Deceive By: - <br />Title: <br />.— <br />EHD 23-0 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/171/08 <br />