Laserfiche WebLink
aRctHIN <br />SAN JOAQUIN COUNTY <br />m`•'ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />• P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />C%PORN <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />s � <br />a� <br />Inspection Date: <br />ag- <br />Facility Addrestill <br />6(1n25 100g4:k 4m <br />Sdmed �,Qcr . <br />Service Request #: <br />A/A- <br />Onsitel�Service_ Technician's N/ame: <br />ICC Service Techniciantinstaller Exp. Date: <br />Manufacturer Training: <br />❑ <br />Leak detector <br />El❑ <br />mechanical Model: <br />SERVICE <br />09se.r✓et5`L( <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Diet; o #- <br />❑ electronic Serial #: <br />CZD" Ao&or & fo ie-ek nustfle <br />❑ line test programmed <br />❑ <br />Leak detector <br />El❑ <br />mechanical Model: <br />-e., ed <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />57a&OtL C <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />IF <br />Y- <br />❑ fall safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fall safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fall safe Serial #: <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 />SERVICE <br />09se.r✓et5`L( <br />Spill bucket & minimum 5 gallon <br />�IL5,1 <br />hour hydrostatic ❑ Incon TS -STS <br />Diet; o #- <br />❑ Caldwell System ❑ Other <br />CZD" Ao&or & fo ie-ek nustfle <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />44 ada r waa41'SUetid- <br />❑ Caldwell System ❑ Other <br />-e., ed <br />Primary piping testing at: <br />❑ <br />psi <br />57a&OtL C <br />minutes <br />e. d Q .� —hwl- dfO '\ <br />Secondary containment testing for: <br />IF <br />Y- <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 0 containmanl components are required to be tested upon <br />installation, 6 months alter, 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 />fivolk 46 <br />09se.r✓et5`L( <br />6uekeF -tea <br />8-V-00aue- duet f* d Q <br />I a?I-leJ <br />Diet; o #- <br />kte /)M1kr. <br />CZD" Ao&or & fo ie-ek nustfle <br />-Ae dnaa <br />Jai v ac. -4 oclA <br />were r 1a a -d axd <br />44 ada r waa41'SUetid- <br />Ile 4g&" <br />-e., ed <br />V <br />A &ae� f 1, 5-ik <br />a 7bp QAtd <br />ed <br />57a&OtL C <br />a-ei aQQ-edu <br />e. d Q .� —hwl- dfO '\ <br />1VQli <br />L <br />IN 1. <br />IF <br />Y- <br />W- <br />S. <br />THIS FACILITY IS SUBJECT <br />TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspec <br />De <br />a Ma a(- <br />Received By: <br />�- <br />— <br />Title: <br />'SCC 4 <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />