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04/15/2015 14:12 2094683433 <br />SJC EHD UNIT 3 <br />L�l <br />PAGE 02/02 <br />SAN JOAQUIN COUNTY <br />mak' ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />` Telephone; (209) 468-3420 Fax. (209) 468-3433 Web: www.slgov.org/Ahd <br />•b <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name; <br />Irispection Date: <br />Leak detector <br />❑ <br />Facility Address; <br />Service Request#: <br />0 electronic -Serial #. <br />U i' • _ v 1 's 314 a <br />onsite Service 7 nician's Name: <br />ICC Service Techniclanfinstaller p, Date: <br />Manufacturer Training: <br />e <br />'?5-14-1_4 <br />g o-11_-1 -115 Woo <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />0 electronic -Serial #. <br />U i' • _ v 1 's 314 a <br />0 line test programmed <br />❑ <br />Leak detector <br />❑ <br />O mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test m rammed <br />�% i A i2 6L � n ' <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />i <br />❑ fall safe Serial #: <br />THIS FACILITY IS <br />❑ NA <br />EHD (nape <br />an��fc� <br />sensor <br />El <br />❑ positive shutdown Model: <br />71e. <br />❑ fail safe Serial A _ <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 96% <br />F1 <br />Overfill prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1. hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System © Other <br />U i' • _ v 1 's 314 a <br />Spill bucket 10 minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic �❑ Incon TS -STS <br />0 Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />�% i A i2 6L � n ' <br />minutes <br />(,�.o ,.t rQ <br />Sqcondary pontainment testin fo <br />a3 <br />UDC(s) l Piping <br />i <br />Sump(s) UST(s) <br />THIS FACILITY IS <br />..'ApgpECTION AT 4NY TIME AT EHD'S CURRENT HOURLY E. <br />EHD (nape <br />an��fc� <br />Testing for theabovecomponents are next due by: <br />ReceNed By: <br />E m o t] 1 ni QcC s t inn SCR r <br />71e. <br />Nate: Pkase be awam that 20 cor"irsrosnt compmvda are r"Limd to be tasted upon <br />Installation, a mons after, 2m every 3a mornhs t weafler. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other see below <br />xThis UST facility Is NOT APPROVED to operate <br />EHD 2344 UST SERVICE REQUEST IN$PECTION REPORT <br />Rev 4/30/12 <br />NCf-)N 2 SDC '-t) 3 <br />a I <br />0101 v1 i 3 <br />U i' • _ v 1 's 314 a <br />J � 6 eA . <br />Pd <br />a l4 � S� • <br />�% i A i2 6L � n ' <br />[ .. 11 <br />(,�.o ,.t rQ <br />L 161 <br />i <br />THIS FACILITY IS <br />..'ApgpECTION AT 4NY TIME AT EHD'S CURRENT HOURLY E. <br />EHD (nape <br />an��fc� <br />ReceNed By: <br />71e. <br />EHD 2344 UST SERVICE REQUEST IN$PECTION REPORT <br />Rev 4/30/12 <br />