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�� <br />:.1 <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.ora/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Mw <br />EMENEEME <br />c,%� ro <br />SERVICE <br />Inspection Date: <br />-4 - <br />Facility Address: (�� <br />Leak detector <br />I <br />Service Request #: <br />Onsite Service Technician's Name: <br />SC Gixrro[C, <br />ICC Ser <br />ice Technician/Installer Exp, Date: <br />q_ b -4CAt1 <br />Manufacturer Training: <br />W • I1-91`1 13r"o 06.14 <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />SERVICE <br />Spill bucket ❑ minimum <br />Leak detector <br />❑ <br />❑ <br />mechanical Model: <br />= C52 <br />❑ <br />electronic Serial #: <br />- 51, 5 <br />Spill bucket ❑ minimum <br />❑ line test programmed <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Leak detector <br />❑ <br />❑ <br />mechanical Model: <br />❑ <br />electronic Serial #: <br />e- 0 1 <br />_ '" <br />o psi V"or e-e.o <br />❑ line test programmed <br />minutes G(' PP ^1 d <br />sensor <br />❑ <br />❑ <br />positive shutdown Model: <br />8 <br />❑ <br />fail safe Serial #: <br />- �� <br />❑ <br />NA <br />❑ <br />Testing for the above components are <br />sensor <br />❑ <br />❑ <br />positive shutdown Model: <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />fail safe Serial #: <br />Cold start of monitoring panel <br />❑ <br />NA <br />Corrosion protection <br />sensor <br />❑ <br />❑ <br />positive shutdown Model: <br />❑ <br />fail safe Serial #: <br />❑ <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 />❑ This UST facility is NOT APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum <br />5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />2c.ca t 0.11 <br />= C52 <br />❑ Caldwell System ❑ Other <br />cit Chock <br />- 51, 5 <br />Spill bucket ❑ minimum <br />5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />vLaw r f tfty <br />e- 0 1 <br />_ '" <br />o psi V"or e-e.o <br />minutes G(' PP ^1 d <br />% <br />KPI <br />_ 5 <br />Secondary containment testing for: <br />8 <br />UDC(s) <br />Piping <br />- �� <br />Sump(s) <br />UST(s) <br />❑ <br />Testing for the above components are <br />next due by: <br />SUBJECT Tb REINSPECTI N AT <br />Note: Please be aware that 20 containment components are required to be tested upon <br />EHD'S CURRENT HO LY <br />installation, 6 months after, and every 36 months thereafter. <br />EHD Inspector: <br />Qt L Ll `. �� <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 />EHD 23-04 , UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />�i¢�e,Q cls <br />. - 5 s. <br />"Cum} <br />2c.ca t 0.11 <br />= C52 <br />cit Chock <br />- 51, 5 <br />_ <br />_ <br />vLaw r f tfty <br />e- 0 1 <br />% <br />KPI <br />_ 5 <br />8 <br />Ct l <br />- �� <br />�- <br />THIS FACILITY IS <br />SUBJECT Tb REINSPECTI N AT <br />ANY TIME AT <br />EHD'S CURRENT HO LY <br />RATE. <br />EHD Inspector: <br />Qt L Ll `. �� <br />Receivedi <br />Title: <br />I o v V <br />Mae, <br />EHD 23-04 , UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />