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3y <br />4 <br />o.Ra� I N• c <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />j 1 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />\',• P; Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />9 -Q"v <br />1 113rAAA- <br />Inspection Date: <br />❑ <br />mechanical Model: kA <br />9 - Q—\ '(1:2 <br />Facility <br />�Address: <br />(( <br />✓� IV , ' Vl � (/ rte-C�d <br />�W�^'� �LC�. <br />Service Request ##: p <br />"'./NOsCr t O <br />O site Service Tecn" i n's Name: ICC <br />` 70. <br />e <br />- I Z -T� chnician/Installer Exp. Date: <br />Manufacturer Training: <br />V <br />r' a� > <br />�- a-1 <br />SERVICE <br />1 113rAAA- <br />Leak detector <br />❑ <br />mechanical Model: kA <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sP�r <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />o <br />❑ NA <br />eQ0\/PU" 4o <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />THIS FACILI <br />❑ fail safe Serial #: <br />EHD InspMr: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail 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 />SERVICE <br />1 113rAAA- <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />(0n <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />sP�r <br />minutes <br />Secondary containment testin9�for: 5-15PLV.1kQ4r <br />I <br />UDC(s) ZS Piping <br />o <br />' Sump(s) UST(s) <br />eQ0\/PU" 4o <br />Testing for the above due by, <br />components are next <br />THIS FACILI <br />KW JbCM cu AA <br />EHD InspMr: <br />Note. Please be aware t containment components are required to be to ted 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 iss APPROVED to operate q This UST facility is NOT APPROVED to operate <br />U6sp-�'v <br />1 113rAAA- <br />65 P <br />' -,_• �� 0 <br />�a <br />-t l,I (Vcc <br />(0n <br />'"Tc yni 0=k 2 <br />_ <br />sP�r <br />�14 <br />(Q <br />o <br />eQ0\/PU" 4o <br />P ou uLiAo m s <br />O <br />THIS FACILI <br />Y IS SUBJECT TO REINSPECTI N Af ANY TIME T EHD'S CURRENT HOURLY RATE. <br />EHD InspMr: <br />Received By: <br />TC��I <br />I �� <br />l <br />Title: <br />EHD 23-04 V UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 I 1 <br />