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l�ti <br />P�•� i N., <br />�o.��..coG $AN JOAQUIN COUNTY <br />�r� � `� ENVIRONMENTAL HEALTH DEPARTMENT <br />`, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />�. .� Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.ora/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />SERVICE <br />f w�CR.c <br />Spill bucket ❑minimum <br />Leak detector <br />❑ <br />❑mechanical <br />Model: <br />� -'S1, <br />❑ <br />electronic Serial #: <br />Spill bucket ❑minimum <br />❑ line test ro rammed <br />❑ <br />❑ 1 hour hydrostatic ❑Incon TS -STS <br />Leak detector <br />❑ <br />❑mechanical <br />Model: <br />"" <br />❑ <br />electronic Serial #: <br />� psi ��� r �—� <br />❑ line test ro rammed <br />THIS FACILITY IS SUBJECT T REINSPECTI NAT <br />�p�� minutes � ( �'� (�` <br />sensor <br />�] <br />❑positive <br />shutdown Model: <br />❑ <br />fail safe Serial #: <br />Sumps) <br />UST(s) <br />❑ <br />❑ <br />NA <br />Note: Please be aware that 2° containment components are required to be tested upon <br />sensor <br />❑ <br />❑positive <br />shutdown Model: <br />Cold start of monitoring panel <br />❑ <br />fail safe Serial #: <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ <br />NA <br />sensor <br />❑ <br />❑positive <br />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 />�'� � <br />SERVICE <br />�� �-� r . <br />f w�CR.c <br />Spill bucket ❑minimum <br />5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑Incon TS -STS <br />i 1 � ` , � � � L r <br />� -'S1, <br />❑Caldwell System ❑Other <br />Spill bucket ❑minimum <br />5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑Incon TS -STS <br />5 2.5 � �� . <br />f f e.UU�v i e' �J a� i <br />+/..�� <br />❑Caldwell System ❑Other <br />O�-�. � S e. 2b <br />"" <br />Primary piping testing at: <br />� psi ��� r �—� <br />V�� <br />THIS FACILITY IS SUBJECT T REINSPECTI NAT <br />�p�� minutes � ( �'� (�` <br />i <br />EHD Inspector: <br />Secondary containment testing for: <br />-�--�_ <br />UDC(s) <br />Piping <br />Sumps) <br />UST(s) <br />❑ <br />Testing for the above components are <br />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 />❑ <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 />�'� � <br />�'Q 8' <br />�� �-� r . <br />f w�CR.c <br />� �. F�1 YJ�+C+t � •— � S 1 ��✓ \ <br />I�f�O <br />�[.�.L1.1 l l,? r <br />i 1 � ` , � � � L r <br />� -'S1, <br />8 �' Glncu - S <br />5 2.5 � �� . <br />f f e.UU�v i e' �J a� i <br />+/..�� <br />O�-�. � S e. 2b <br />"" <br />THIS FACILITY IS SUBJECT T REINSPECTI NAT <br />ANY TIME AT <br />EHD'S CURRENT HO LY RATE. <br />EHD Inspector: <br />Received <br />-�--�_ <br />Title: <br />EHU 23-04 J UST SERVICE REQUEST INSPECTION REPOR <br />Rev 4/3Q;12 <br />