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O.p'Q U I N. •.0 <br />116SAN aJOAQUIN COUNTY 4b <br />-� <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />'• 3 P <br />9��FORa` <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />�-y r % <br />1(�� V � 1P 0 l `. ) <br />r� <br />9 1 q el T <br />Facility Address: <br />Service Request : <br />-�342%5 Ira , Ii <br />-gip C)O.7 02C3 q <br />Onsite Service Tech 'cia 's Name: <br />ICC nice h . 'an/frz96sW r Exp. Date: <br />Manufacturer Training: <br />W <br />❑ mechanical Model: <br />SERVICE <br />it /�I. -_� ' �' 11 /i a ' / _I / ti��. s, 1 / I t isLi <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 />(-")sensor <br />1�1 <br />J�J <br />positive shutdown Model: <br />ail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />ositive shutdown Model: <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 />,ail safe Serial #: <br />❑ <br />❑ INA <br />sensor <br />sitive shutdown Model: ZQ <br />Uosafe Serial #: <br />U) <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 />it /�I. -_� ' �' 11 /i a ' / _I / ti��. s, 1 / I t isLi <br />Spill bucket )q minimum 5 gallon <br />X1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System XOtherA.{ "no3�- <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />1111 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) Piping <br />Sump(s) Ill <br />❑ <br />Testing for the above components are next due by: <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 <br />❑ <br />Corrosion protection <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 ( J' UU/ST� SE VICE REQUEST INSPECTION REPORT <br />Rev 4/30/124 /a (/ ��C/✓� G cv� �C �J/v4J� {"."�/, ate✓© h' ti " ' d <br />it /�I. -_� ' �' 11 /i a ' / _I / ti��. s, 1 / I t isLi <br />t.l <br />,A1 i� �► ��rallW-Sik"11=1 <br />4ZI 2; Loll <br />EHD Inspector: <br />i �. <br />�= � <br />EHD 23-04 ( J' UU/ST� SE VICE REQUEST INSPECTION REPORT <br />Rev 4/30/124 /a (/ ��C/✓� G cv� �C �J/v4J� {"."�/, ate✓© h' ti " ' d <br />