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)�p0.e''CO <br />.� SAN JOAQUIN COUNTY <br />r _err 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 />���lFORN`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />2-S rc., <br />Inspection Date: <br />t t 2of <br />Facility Address: <br />- 8 L+ r 1� 9-0 j(- fM <br />Service Request #: <br />s P00 6 I! o <br />Onsite Service Technician's Name: <br />ICC Sery ce Technician/Installer Exp. Date: <br />Manufacturer Training: <br />q <br />❑ <br />SERVICE <br />-, <br />_ Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />El line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Z S <br />❑ electronic Serial #: <br />❑ <br />❑ line test ro rammed <br />2°- <br />_ sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />_ sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: _ <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: _ <br />Rece v <br />❑ fail safe Serial #: <br />Title: <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 />-, <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 />10-uu1- <br />❑ Caldwell System ❑ Other <br />Z S <br />Primary piping testing at: <br />❑ <br />psi <br />2°- <br />minutes <br />i-tv <br />Secondary containment testing for: C a,�o <br />UDC(s) (/ iping <br />Wump(s) UST(s)as�/ting <br />Wfo he a ove co nts are next due by: <br />Note: Please be awar hat 2° containmem components are required to be tested ipon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />This UST facility is NOT APPROVED to operate <br />1-0h O -A I) -Kt <br />-, <br />" s O <br />10-uu1- <br />Z S <br />-z : <br />si <br />2°- <br />i-tv <br />THIS ACILITY IS SUBJECT TO 0EINSPECTION <br />AT JNNY <br />TIME AT EHD'S CURRENT HOURLY RATE. <br />[EFUT.7iecto <br />Rece v <br />Title: <br />EHD 23-04 <br />__j <br />Rev 4/30/12 <br />S7-,1; <br />Ll/ UST S(E�ICE REQUEST IN6kCTION REPORT <br />