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PpUlry �w o.• ""' •.c SAN JOAQUIN COUNTY a ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 c _ ; 4 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.org/ehd UNDERGRIDUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: �y 11 ll C1h 4 w ic® Inspection Date: 1 1 C/1 Facility Address: Gu Service Request #: Onsite Service Technician's Name: S� &rroi0. ICC Ser ice Technician/Installer Exp, Dat7t: '- 6 nufacturer Training: CU ❑ This UST facility is APPROVED to operate SERVICE SERVICE Spill bucket ❑ minimum Leak detector 1111111111111111110 ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ line test programmed ❑ Caldwell System ❑ Other Leak detector 1 ❑ ❑ mechanical Model: o vcvo�y ❑ electronic Serial #: Secondary containment testing for: ❑ line test programmed THIS FACILITY IS _ sensor EHD'S CURRENT HO LY Sump(s) ❑ positive shutdown Model: next due by: ❑ fail safe Serial #: ❑ NA ❑ Cold start of monitoring panel sensor Corrosion protection ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LIS letter 150-1) ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ?gddd- PCL� ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other e- 6 1 Primary piping testing at: bI P11,11,A psi V"a r rdb% o vcvo�y ASL, minutes c(� r Secondary containment testing for: �- THIS FACILITY IS UDC(s) Piping EHD'S CURRENT HO LY Sump(s) UST(s) ❑ Testing for the above components are next due by: Title: j Note: Please be aware that 20 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate 7l� EHU 23-04 � UST SERVICE REQUEST INSPECTION REPORT Rev 4/30;12 CUA r3 lQz4 Rud I( ?gddd- PCL� PON- ��' Ghcusm +/aW r f eov e- 6 1 bI P11,11,A L Cf I �- THIS FACILITY IS SUBJECT Tb REINSPECTI N AT ANY TIME AT EHD'S CURRENT HO LY RATE. EHD Inspector: Received Title: j t Q/t 7l� EHU 23-04 � UST SERVICE REQUEST INSPECTION REPORT Rev 4/30;12