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qu`,1��� SAN �OAOUIN COUNTY <br />/�•. �.e �.o . <br />Z:--�,,,–. •�y ENVIRONMENTAL HEAS�o �OP, CA 95205-6232 <br />'y. �� 1868 East Hazelton Ave 209 468-3433 Web: �NiNvv.s� v—or��ehd <br />�'�`'' Telephone: (209) 408-3420 Fax: ( ) <br />�;� XPi <br />�q�l,�oRt?/ <br />UST PROGRAM SERVICE R1=t�UEST II`fSPSCTION REPOR <br />U�IDERGROUN'D STORAGE TANK ( � Inspection Date: <br />Facility Name: <br />Facility Address: � , n - . <br />-�, V \ Date <br />ICC Service Techntcianllnstal�• <br />Onsite Service Technician's Name: n ^ � �, <br />-���- � �� <br />SERVICE <br />Leak detector <br />❑ mechanical Model: _ <br />❑ electronic Serial #: _ <br />❑ line test pro rammed <br />Leak detector <br />❑ mechanical Nlodel: _ <br />❑ electronic Serial #.: <br />❑ line test ro rammed <br />�_ sensor <br />❑ positive shutdown Model: _ <br />❑fail safe Serial #: <br />❑ �I A <br />sensor <br />❑❑ po�hutdown Ntodel: _ <br />❑ fail safe Serial #: <br />❑ NA <br />� sensor <br />❑ positive shutdown Model: _ <br />❑fail safe Serial #: <br />❑ NA <br />❑ Drop tube with mechanical overfill at 95% <br />❑ Drop tube with mechanical overfill at 95% <br />❑ Overfill prevention (see LG letter 150-1) <br />This UST facility is APPROVED to operate <br />�— <br />Service Request #: <br />N1an�a urer Tr fining: <br />SSR'JICE <br />Spill bucket <br />❑ ❑ 1 hour hydrostatic <br />❑ Caldwell System <br />Spill bucket <br />❑ ❑ 1 hour hydrostatic <br />❑ Caldwell System <br />Primary piping testing at: <br />❑ psi <br />minutes <br />❑ minimum 5 gallon <br />❑ Incon TS -STS <br />❑ Other <br />❑ minimum 5 gallon <br />❑ Incon TS -STS <br />❑ Other <br />Secondary containment testing for: Piping <br />UDC(s) UST(s) <br />Sumps) <br />❑ I Test ni g for the above components are next due by: <br />nstallatiions6 monlhsrafteatand eveay 36 month P hereaftere required to be tested upon <br />❑ Cold start of monitoring panel <br />❑ Corrosion protection <br />^� Other: see below <br />_ � �,�� <br />'[� This UST facility is NOT APPROVED to operate <br />�� �� � � ' 11 �.�� � � � L � �-� <br />c�1 SI <br />�; �t �.L �, ���,�� cc. r � <br />��� . �.� <br />>;��L = �� <br />THIS FACILITY IS SUBJECT TO REIN RPECe1dON T <br />D Inspector <br />�� C;l � (,�1 _ <br />EHD 23-04 <br />Rev 4130/12 <br />_� <br />��� <br />-t; N <br />S�-� L� . 2 <br />a �� y ,1 . <br />IME AT EHD'S CURB <br />HOURL RATE. <br />1 iue: � <br />� ;;✓�.� 1-� JL:� � � � rvl. r�,. <br />UST SERVICE REQUEST INSPECTION REPC <br />