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O.P''Qu I N•.0 AN alOAG1UIN COUNTY Q. �+ ENVIRONMENTAL HEALTH DEPARTMENT N lam:. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 �. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd CqUNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: fr CA - Kle 4 e &t- 10(-- (--I Inspection Date: ❑ ❑ mechanical Model: ` OL, Facility Ad ress: Service Request #: %C-Qa;5 1�. e VO- c t-0AsC00 0 Onsite Service Technician's Name: ICC Service Technician/installer Exp. Date: Manufacturer Training: Aelk rC{2 Lxhe- TS cl a C A "-e r s —n -10-0),o allX< - 9- 3- 2- u SERVICE fr CA - Kle 4 e &t- 10(-- (--I Leak detector ❑ ❑ mechanical Model: ` OL, ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: Q ov o yr �fi tp �-1 ❑ electronic Serial #: ❑ ❑ line test programmed � 4tcAill s� sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ 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 LG letter 150-1) I This UST facility is APPROVED to operate SERVICE fr CA - Kle 4 e &t- 10(-- (--I Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ` OL, ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS e4p, U V\Q kw YCOKo a=2 ❑ Caldwell System ❑ Other Q ov o yr �fi tp �-1 Primary piping testing at: ❑ psi � 4tcAill s� minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 2° 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 0 Ij Q -'� Q U vte- -k 0-6-t- ., , ❑ This UST facility is NOT APPROVED to operate lLu ZIAQ geXVQ- 0. \ <-,alk-o fr CA - Kle 4 e &t- 10(-- (--I 01 I$q U s e -,o cid Vl� c Ilk `L -L d --V►o n . Rpt ` OL, rta W01,15 Qk zd e4p, U V\Q kw YCOKo a=2 r .;IV v46L,� s9XVed �bm6pj Q ov o yr �fi tp �-1 THIS FACILITY IS SUBJECT TO REINSPECTIOJ AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspector: a� ReceivedB yTitle: � 4tcAill s� G w EHD 23-04 Rev 4/30/12 -10 do 2c 9 UST SERVICE REQUEST INSPECTION REPORT Isc a,��',✓ate.