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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205mil <br />Telephone: (209) 4611 Fax: (209) 4611 Web: www.:,ic��.org/ehd <br />UNDERGROUND aTORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />C/�YW1I' <br />Inspection Date: <br />e)���) <br />Facility Address:( <br />Leak detector <br />Service <br />�%Request #: <br />❑ <br />On tt Service Technician's Name: <br />ICC Service Tech nicianflnstaller ll III <br />Manufacturer Training: <br />❑ This UST facility is APPROVED to operate <br />I MW IV, rol <br />SERVICE <br />SERVICE <br />Spill bucket ❑ minimum <br />Leak detector <br />❑ <br />❑ <br />❑ <br />mechanical <br />Model: <br />❑ <br />electronic <br />Serial #: <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon T&STS <br />❑ line test programmed <br />❑ Caldwell System ❑ Other <br />Leak detector <br />❑ <br />❑ <br />mechanical <br />Model: <br />❑ <br />electronic <br />Serial #: <br />Secondary containment tes 191 for: <br />❑ line test programmed <br />UDC(s) jmc6cPiping <br />sensor <br />❑ <br />❑ <br />positive shutdown <br />Model: <br />next due by: <br />❑ <br />fail safe <br />Serial #: <br />❑ <br />NA <br />❑ <br />Cold start of monitoring panel <br />sensor <br />Corrosion protection <br />❑ <br />❑ <br />positive shutdown <br />Model: <br />❑ <br />fail safe <br />Serial #: <br />❑ <br />NA <br />•WM <br />I. J <br />M -• <br />sensor <br />❑ <br />❑ <br />positive shutdown <br />Model: <br />❑ <br />fail safe <br />Serial #: <br />❑ <br />NA <br />❑ <br />Drop tube with <br />mechanical overfill at 95% <br />❑ <br />Drop tube with <br />mechanical overfill at 95% <br />❑ <br />Overfill prevention (see I letter 151 <br />❑ This UST facility is APPROVED to operate <br />I MW IV, rol <br />�0 This UST facility is NOT APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum <br />5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon T&STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum <br />5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon T&STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment tes 191 for: <br />UDC(s) jmc6cPiping <br />Sump(s) <br />III <br />1 � , <br />Testing for the above components are <br />LA <br />next due by: <br />10 <br />Note: Please be aware that 2` containment components are required <br />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 />HD 23-04 V <br />ev /� <br />UST SERVICE REQUEST INSPECTION REPORT <br />9/30/12 <br />III Jill 1 11 111 <br />1 TAW <br />el <br />Man <br />I OA ' W, <br />1.t I NO <br />1 � , <br />1 l� <br />10 <br />s A <br />mini <br />- <br />. <br />•WM <br />I. J <br />M -• <br />�1 <br />HD 23-04 V <br />ev /� <br />UST SERVICE REQUEST INSPECTION REPORT <br />9/30/12 <br />