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o Pqu I !`!. •.c <br />?' SAN JOAQUIN COUNTY <br />Q �{ _NVIRONMENTAL HEALTH DEPARTMENT <br />_ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si ocov.or /q ehd <br />A�/FORS <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />r <br />Inspection Date: <br />Facility Address: <br />1.3CiC) Y6 ao k cc <br />Service Request #: <br />S(Z loo (s�o 1 <br />Onsit Serv'ce Tec nician's Name: <br />'lam <br />ICC Service echnician/installer Exp. Date: <br />Manufacturer Training: <br />❑ line test programmed <br />Z -7,2 -7 <br />G �^w - � .� 13 <br />J <br />SERVICE <br />r <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />41A, <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />R;getBy"/ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <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 />❑ <br />Overfill prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />r <br />C Spill bucket ❑ minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />41A, <br />❑ Caldwell System iXOther &rc <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 />R;getBy"/ <br />minutes <br />Title: <br />Secondary containment testing for: <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 20 containment components are required 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 />❑ <br />Other: see below <br />0 This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 4/30/12 <br />-y-. <br />UST SERVICE REQUEST INSPECTION REPORT <br />r <br />fV <br />41A, <br />-' <br />THIS FACILITY IS SUBJECT TO REINSPEC N AT <br />W TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />R;getBy"/ <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />-y-. <br />UST SERVICE REQUEST INSPECTION REPORT <br />