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RQuIN <br />�o.• •.co SAN JOAOUIN COUNTY 41 <br />Ga ENVIRONMENTAL HEALTH DEPARTMENT <br />>!. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: WWWsigov.or4/ehd <br />�/FORD <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />-7- <br />on":!!4 3c <br />Facility Address: <br />Service Raguest #: <br />*�'3 L <br />152a�:02 Cod 1 <br />Onsite Service Technician's Name: ICC Service Technician/installer Exp. Date: <br />Manufacturer Training: <br />�' I'L—S—PL-r <br />❑ <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />It �r tri s y — �� tpp!– -k6t ^ <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION A ANY 1WE AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />XjZ <br />sensor -r -ill <br />El positive shutdown Model: \1-+ Sol <br />❑ fail safe Serial <br />NA, <br />sensor A�� <br />❑ positive shutdown Model: Zz� <br />❑ fail safe Serial #: l2 *1 O <br />TSZ NA <br />sensor <br />❑ positive shutdown Model• (L 20 <br />❑ fail safe Serial #: Tiq,43 <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 />SERVI E <br />`; It Spill bucket )Q minimum 5 gallon <br />1 hour hydrostatic ❑ Incon TS -STS <br />U1, <br />It �r tri s y — �� tpp!– -k6t ^ <br />❑ Caldwell System 'Q Other •►tt-ili <br />THIS FACILITY IS SUBJECT TO REINSPECTION A ANY 1WE AT EHD'S CURRENT HOURLY RATE. <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) 411 Pi I <br />Sumps) rx UST(s) <br />Testing for the above components are next due by: <br />no, n , 1 ^—Z-aA ! rl sw>r yo5 cl,) <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 />Cold start of monitoring panel 1::� f. <br />❑ <br />Corrosion protection s 4- <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />011r,11C 10 7 G'to kJ ✓Ocrr 1 NvZs . <br />1 <br />= "-- -hJ, be, = `� <br />It �r tri s y — �� tpp!– -k6t ^ <br />el`( res — .7 <br />k4- -� <br />THIS FACILITY IS SUBJECT TO REINSPECTION A ANY 1WE AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspec O . <br />Z/aMA- <br />a2fA <br />Re( Title: <br />F <br />EHD 23-04UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 t/� <br />