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O.p4uIN'•.0 <br />• <br />Facility Address: <br />is35E "C0d�'D A;N/QXq 11 w4ty. cA. 9G3fD4 <br />SAN JOAQUIN COUNTY <br />/ <r. <br />yI—�) <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Manufacturer Training: <br />II�13�1`� <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />❑ line test programmed <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />/FORS <br />❑ <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Y(RG Roight <br />Inspection Date: <br />lOaoPjeR <br />Facility Address: <br />is35E "C0d�'D A;N/QXq 11 w4ty. cA. 9G3fD4 <br />Service Request #: <br />SR�u}�aqq� <br />Onsite Service Technician's Name: <br />NUtM-D THbYYIC1S <br />ICC Service Technician/Installer Exp. Date: <br />Install 11/ltoj obve�derR�Di-(4�— <br />Manufacturer Training: <br />II�13�1`� <br />SERVICE <br />bane a anK- ,4024jQ50s anhulAR QMCs . <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />h yuan d <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />e#cy <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor (Alf)LAW pp, <br />qli 3VO"3�3 <br />u uns Inc. <br />❑ positive shutdown Model: <br />EHD Inspector: <br />❑ fail safe Serial #: V4W <br />R eiv <br />❑ NA <br />❑ <br />sensor <br />El❑ <br />positive shutdown Model: <br />❑ <br />❑ fall safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />E-1❑ <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 />❑ <br />Overfill prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />bane a anK- ,4024jQ50s anhulAR QMCs . <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />h yuan d <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />- <br />❑ Caldwell System ❑ Other <br />e#cy <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />u uns Inc. <br />Secondary containment testing for: <br />EHD Inspector: <br />UDC(s) Piping <br />R eiv <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note. Please be aware that 2° containment components are required to be tested upon <br />installation, 6 months atter, 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 />Oh V <br />bane a anK- ,4024jQ50s anhulAR QMCs . <br />b b ervked cj4ph <br />coIoor cfi i ci a h vpMcyow <br />Wyo.wAlcir <br />VC <br />h yuan d <br />t annular sev►sm- was mmiled ovi 10 ifo ibi--. <br />- <br />D S ►I awe i hncare <br />e#cy <br />n e <br />GIl n( a <br />II I�r�e frmm <br />fiam <br />u uns Inc. <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />R eiv <br />d By: <br />Title: <br />ERE, 23-04 <br />Rev 4;30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />