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?I l N. <br />' SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />{ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />P 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 />n5 r. <br />Inspection Date: <br />❑ <br />❑ mechanical Model: <br />Facility Address: <br />Service Reques <br />c2+40 <br />J /� <br />n c `.S L L.i <br />J#�: l /'� <br />S4 0 0/ i,3 1 Lt► <br />Onsite Service Technician's Name: <br />]cc service Techniciantinstalle Exp. Date:,Manufacturer <br />Training: <br />❑ line test programmed <br />Recei d Bye <br />sensor <br />❑ <br />SERVICE <br />n5 r. <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model; <br />❑ electronic Serial #; <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />Recei d Bye <br />sensor <br />❑ <br />❑ positive shutdown Model,- <br />❑ fail safe Serial #: <br />7-1 NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model.- <br />odel:❑ <br />0fail 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 />y - This UST facility is APPROVED to operate <br />SERVICE <br />n5 r. <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 />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />psi <br />Recei d Bye <br />minutes <br />Title: <br />L <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 21 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 />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />-c- <br />n5 r. <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD Insp or: <br />Recei d Bye <br />Title: <br />L <br />EHD 23-04 j UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4130112 <br />