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O Pa U l N• •.0 <br />SAN JOAQUIN COUNTY <br />N - ENVIRONMENTAL HEALTH DEPARTMENT - <br />': 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*gov.om/ehd <br />9��FOR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />L t/e-s s <br />7/2z// Z <br />Facility Address: <br />1 SS3 CD t !Jlel Qt Porgy <br />Service Request #: <br />sly Q 6 6 4 6 4��I <br />Onsite Service Techniciap,� Nam <br />ICCwl/a ice TRchnicia illns ler xg. Date: <br />mar tlAp-a <br />Manufacturer Training: <br />J LACE Gtnn Va I Ae <br />wo� o�nc at/, l <br />❑ <br />a <br />SERVICE <br />[�M'vb <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />G�e� l>,,et,.-i C-4 S "t 4,ML) c <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />s <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />l�rcwn i �-► <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT Y TIME 6T EHD'S CURRENT HOURLY RATE. <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />LEl <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 />❑ This UST facility is APPROVED to operate <br />SERVICE <br />[�M'vb <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />G�e� l>,,et,.-i C-4 S "t 4,ML) c <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />s <br />Primary piping testing at: <br />❑ <br />psi <br />l�rcwn i �-► <br />minutes <br />Secondary containment testing for: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT Y TIME 6T EHD'S CURRENT HOURLY RATE. <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 />Cold start of monitoring panel <br />LEl <br />Corrosion protection <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />onsi <br />[�M'vb <br />cam, a7 Slav -e- s <br />wG.rt <br />. <br />G�e� l>,,et,.-i C-4 S "t 4,ML) c <br />s <br />d +-- a,U A —27� <br />cl. <br />,iii% <br />l�rcwn i �-► <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT Y TIME 6T EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />A4 - N <br />Received By: <br />Title: <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />