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PQtI I N <br />?° . � '•°� SAN JOAQUIN COUNTY <br />.- ENVIRONMENTAL HEALTH DE=PARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.smgov.org/ehd <br />QtlROR�` <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name:rr <br />C> IV--, n I OIJ- i <br />Inspection Date: <br />rX�.Y17� <br />❑ mechanical Model: <br />—J —I <br />Facility Address: <br />THISE4CILOTY ISAYBJECT TO REINSPECTION AT ANY TI AT EHD'S CURRENT HOURLY RATE. <br />Service Request #: <br />❑ <br />Leak detector <br />❑ <br />Onsite Service Technician's Nhmq <br />IC Service Technic i Installer Exp. Date: <br />Manufacturer Training: <br />❑ <br />❑ line test programmed <br />SERVICE <br />C> IV--, n I OIJ- i <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THISE4CILOTY ISAYBJECT TO REINSPECTION AT ANY TI AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />El electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <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 />Overfill prevention (see LG letter 150-1) <br />2r This UST facility is APPROVED to operate <br />SERVICE <br />C> IV--, n I OIJ- i <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THISE4CILOTY ISAYBJECT TO REINSPECTION AT ANY TI AT EHD'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 />Testing for the above components are next due by: <br />Note:Please be aware that 2° containment components arerequired 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 />i <br />EH 23-04 <br />Rev 4/30112 <br />UST SERVICE REQUEST INSPECTION REPORT <br />C> IV--, n I OIJ- i <br />THISE4CILOTY ISAYBJECT TO REINSPECTION AT ANY TI AT EHD'S CURRENT HOURLY RATE. <br />EHD inspe r: <br />Received ,/ <br />/ <br />i <br />EH 23-04 <br />Rev 4/30112 <br />UST SERVICE REQUEST INSPECTION REPORT <br />