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O PqU I N, •.0 <br />SAN JOAQUIN COUNTY <br />c. -..-r"' 'a ENVIRONMENTAL HEALTH DEPARTMENT <br />y �X 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sioov.ora/ehd <br />q�%FORa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />111411111 "*A <br />Leak detector <br />Inspection Date: <br />04-03 -W'1 <br />Facility A dress: <br />3-2-02 �Aj\ast <br />HaMVW <br />W^Q) <br />Service Re que-st #:C <br />Onsite Service a <br />0ft-r-Is. <br />nician's Name: <br />r -r <br />Leak detector <br />ICC Service Technician/installer Exp. Date: <br />4 <br />Training: <br />V— L& <br />VV— <br />❑ electronic Serial #: <br />❑ <br />d <br />W 1 9 <br />SERVICE <br />111411111 "*A <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />t . , NOWMA A <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <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 />"K This UST facility is APPROVED to operate <br />SERVICE <br />111411111 "*A <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 />. f �� f f� ■ Y Q� <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />t . , NOWMA A <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 21 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <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 />It MARMISFAN1411� <br />111411111 "*A <br />112? IMMAARWrIUM 01 <br />WM NMI! <br />. f �� f f� ■ Y Q� <br />A IIII <br />SII! k ARR <br />t . , NOWMA A <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />