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SAN JOAQUIN COUNTY <br />Q. + ENVIRONMENTAL HEALTH DEPARTMENT <br />`N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />A r -c D hoc k+cA <br />Inspection Date: _ <br />J CL I\ 15 2-o <br />Facility Address: <br />i6 �. -4—ia rel , a� <br />Service Request Ys <br />'qq ieoa 3, <br />Amechanical Model: <br />66 <br />Onsite Service Technician's Name: ICC ServiceTech ian/Installer Exp. Date: <br />J o.� ��r-�n?�� 1� 6 <br />Manufacturer Tr fining: <br />kz,�Lql�� <br />��I�zt�s-//y <br />❑ line test programmed <br />❑ <br />SERVICE <br />- -A T r olLzer=P I It a (a -km <br />V.x,�z I Leak detector <br />C <br />. <br />Amechanical Model: <br />U 1 S S` o e- S cu (1 . t & " <br />,electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />Leak detector <br />1 <br />E] mechanical Model: _ ( _ <br />0 electronic Serial #: <br />❑ <br />❑ line test programmed <br />CII I szrrser IP-,tk- <br />�it4 <br />Model: (' _ <br />faif-safe 1� 4rLM:� Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />Drop tube with mechanical overfill at 95% <br />il <br />Overfill prevention (see LG letter 150-1) 14/V114 1C��a <br />. <br />XThis UST facility is APPROVED to operate <br />Z <br />SERVICE <br />- -A T r olLzer=P I It a (a -km <br />Spill bucket Elminimum 5 gallon <br />El <br />1 hour hydrostatic ❑ Incon TS -STS <br />U 1 S S` o e- S cu (1 . t & " <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'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 20 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 />❑ <br />Corrosion protection <br />Other: see below 13r1aVG> VP4�A S <br />❑ This UST facility is NOT APPROVED to operate <br />,-�e 9I d ok -10 , 3 <br />- -A T r olLzer=P I It a (a -km <br />�4-s+-dr Jt <br />v I J -5 c, r't 63 o ✓ 2b 13 JjAYTftc ci noPa. .r r) I' & 144-. SSM <br />U 1 S S` o e- S cu (1 . t & " <br />^ <br />/ r� (� <br />Q r T 1 rot 40 V .Q rSt 0-yC IrU r <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHDI spector: <br />Received y: <br />Title: <br />EHD 23-6 (V , zo 0-4-0 t lvl)e+ yf- (U "OT, UST S UV}CF. REQUEST INSPECTIO J REPORT <br />Rev 4/30/12 C ion L T� r Ir11K � Lf ri YC" dY� � iT �Or <br />