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oPQutN C <br />�•'�'`"�'•O� <br />SAN <br />Inspection Date: <br />.lOAOUIN COUNTY <br />~orf` <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Facility Address: <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siClov.org/ehd <br />9�%F0 <br />-jZp-ZH'khkAje-ra. <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />0121min, <br />Inspection Date: <br />—7,// <br />❑ mechanical Model: <br />_//_ <br />Facility Address: <br />THIS FACILITY IS SUBJECT TO REINSPECTI N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />It <br />Service Request #: <br />-jZp-ZH'khkAje-ra. <br />Leak detector <br />5(2-01c> &;,-7 10 <br />❑ mechanical Model: <br />1& <br />Onsite Service Technician's Name: <br />❑ line test progirammed <br />IC Service Technician/installer Exp. Date: <br />Manufacturer Training: <br />tS fail safe Serial #:'PIPS p4 _ f ffii4 <br />V12 - <br />SERVICE <br />0121min, <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTI N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />It <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test progirammed <br />'jy sensor <br />'S positiveshutdown Model: [//ZZbg <br />tS fail safe Serial #:'PIPS p4 _ f ffii4 <br />❑ NA <br />sensor <br />19 positive shutdown Model: O! <br />�9 fail safe Serial #: 15 <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <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 />0121min, <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECTI N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />It <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for* <br />UDC(s) 57�fj 11 <br />Sump(s) UST(s) <br />Testing for the above components are next due by: <br />rJ/A <br />Note: Please be aware that 2° 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 />❑ <br />Other: see below <br />This UST facility is NOT APPROVED to operate <br />EHD 23-04 101 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />0121min, <br />W atn <br />THIS FACILITY IS SUBJECT TO REINSPECTI N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />It <br />EHD Inspec <br />Received y: - / <br />Title: <br />EHD 23-04 101 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />