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Op`QUIk• C ?•'�' •o SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT y.. ` 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd a�fPOR� UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: f2 - c-,> •7l 33 ❑ F cilityyAddress: Service Request #: 7,_9�� Pj`'''1 /� i:�, �a0---> .5 Onsite Service Technician's Name: ICC Se ice Technician/installer Exp. Date: Manufacturer Training: 01 e-� ❑ mechanical Model: SERVICE C4, — o w- Leak detector ❑ ❑ mechanical Model: Z4 ❑ electronic Serial #: 4 Imo- '✓' L I ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: TAC ❑ fail safe Serial #: ME AT EHD'S CURRENT HOURLY RATE. ❑ NA 15< sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: rEl ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LIS letter 150-1) ❑ This UST facility is APPROVED to operate SERVICE C4, — o w- Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS Z4 ❑ Caldwell System ❑ Other 4 Imo- '✓' L I Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: TAC UDC(s) Piping ME AT EHD'S CURRENT HOURLY RATE. Dj.�--Sump(s) UST(s) 15< Testing for the above components are next due by: Title: Note: Please be aware that 21 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection rEl Other: see below .,a This UST facility is NOT APPROVED to operate EHID f 4 Rev 0/06/ UST SERVICE REQUEST INSPECTION REPORT C4, — o w- �dL�^ -' r h . ci e P S Z4 11 h- 4 Imo- '✓' L I be TAC ITY_ IS SUBJECT TO REINSPECTION AT ANY ME AT EHD'S CURRENT HOURLY RATE. EHD 1pspe 7e)ived By: Title: EHID f 4 Rev 0/06/ UST SERVICE REQUEST INSPECTION REPORT