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UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: its / �/ .1 , I1 Inspection date: SAN JOAQUIN COUNTY 4 1 mo*tv" Service Request #: ENVIRONMENTAL HEALTH DEPARTMENT �. Icervice Technicianllnstaller Exp. Date: 3 � 4 III I 600 East Main Street, Stockton, CA 95202-3029 Leak detector ❑ Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd .: 1 � �iA 1 f ❑ electronic Serial #-. UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: its / �/ .1 , I1 Inspection date: Facility Addr�es�s: �� y �4�.l"[Dot �v� 4 1 mo*tv" Service Request #: Onsite Service Technician's Name: dd - � G Icervice Technicianllnstaller Exp. Date: 3 � 4 III I Manufacturer Training: la, SERVICE its / �/ .1 , I1 Leak detector ❑ ❑ mechanical Model: '� % /r ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: .: 1 � �iA 1 f ❑ electronic Serial #-. ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: L❑ electronic Serial #: ❑ line_ test programmed sensor AW kh S El positive shutdown Model: _Q I ❑ 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 } SERVICE its / �/ .1 , I1 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS '� % /r ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT Caldwell System ❑ Other .: 1 � �iA 1 f Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: L❑ psi minutes 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 2° containment components are required to be tested upon installation, & months after, and every 35 months thereafter. Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below i �� . ► LL� a'�. �% 1� ■, 1 d 11I : �� its / �/ .1 , I1 �:+i�. I '_, a.' 6 1 a i �• 1 KI '. '� % /r FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLYTHIS .: 1 � �iA 1 f 4W M AR M A EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 11/171108