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�Aat u f <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*gov.org/eh.d <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Q �J V11 ► <br />Inspection Date:C�-� <br />❑ <br />GQ"� a.)-� <br />l <br />) t <br />Facility A)` dress: <br />` (Jt A <br />Service Request #: <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />Onsite bervice Technician's Name: <br />ICC Servide Technic ian/Inst4 ler xp. Date: <br />Manufacturer Trainingop <br />-,5- q - <br />IZ <br />��' <br />VF-��� <br />V1V► - 1 _ <br />SERVICE <br />Q �J V11 ► <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />` (Jt A <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME ATE D'S CURRENT HOURLY RATE. <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 95910 <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />Q �J V11 ► <br />Spill bucket ❑ minimum 5 gallon <br />Y ' r <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System Other (A f <br />Spill bucket ❑ minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -$TS <br />` (Jt A <br />cf S u e W ctc <br />Elr <br />Caldwell System X6 r <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />vA U of fv <br />Secondary containment testing for: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME ATE D'S CURRENT HOURLY RATE. <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 2° containment components are required to be tested upon <br />installation. 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below <br />XThis UST facility i NOT APPROVE to operate <br />`S1 <br />Q �J V11 ► <br />L (w l <br />Y ' r <br />c l l�\ OLA <br />` (Jt A <br />cf S u e W ctc <br />vA U of fv <br />a u I A0 OI10-.r <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME ATE D'S CURRENT HOURLY RATE. <br />EHD Inspector: .. <br />wV,, <br />Re d By: � � <br />Title: <br />[� <br />EHD 23-04 <br />Rev 4/30/12 <br />/ f - <br />UST SERVICE REQUEST INSPECTION REPORT <br />