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oAqu r N. <br />.. .FE' •o� SAN JOAQUIN COUNTY <br />;er r -r ti ENVIRONMENTAL HEALTH DEPARTMENT <br />lw: h ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />'7 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />l .6Et <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility N me: <br />-LipvQ,,n <br />Inspection Date: <br />Facility Address: <br />a v. moo() �re,e,� �� <br />Service Request #: <br />0107 3s g �- <br />Onsite Service Technician's Name: <br />ICC Se ice Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ line test programmed <br />❑ <br />�J <br />SERVICE <br />Lo <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />KA, rj , <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />Title: <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />❑ This UST facility is APPROVED to operate <br />SERVICE <br />Lo <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 />❑ Caldwell System ❑ Other <br />KA, rj , <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <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 20 containment components are required 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 />Title: <br />Other: see below <br />X This UST facility is NOT APPROVED to operate <br />yA sa�b�p <br />Lo <br /><Z) n G2 <br />-- <br />KA, rj , <br />acl <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />Received By: <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />v_ ..-t e <br />UST SERVICE REQUEST INSPECTION REPORT <br />