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AQu I Iy. <br />�o.E.co SAN JOAQUIN COUNTY <br />e - a *ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />Cq�%FOR�`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />a j <br />`n (_ 1 <br />,�j <br />AW <br />1 � <br />Inspection Date: <br />L C- "' t �i <br />F cI", d_dress' n <br />Service Request #: <br />t , o <br />a <br />I's <br />❑ <br />Leak detector <br />Onside Service Technici Name: <br />❑ mechanical Model: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />I <br />SERVICE <br />l �A <br />Leak detector <br />UMI Lai <br />❑ <br />❑ mechanical Model: <br />� <br />❑ electronic Serial #: <br />t , o <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />t <br />V1 <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <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 />❑ This UST facility is APPROVED to operate <br />SERVICE <br />l �A <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />� <br />❑ Caldwell System ❑ Other <br />t , o <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />t <br />V1 <br />Primary piping testing at: <br />❑ <br />psi <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 20 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 />!-4 <br />l �A <br />6t -Vi' __'IA <br />H, f4t Qt '1 k11i <br />� ,� <br />� <br />� <br />t , o <br />tL <br />t <br />V1 <br />l,- <br />THIS PACILITY IS SUBJECT TO RE PEC <br />N AT ANY TIME AT EHD'S CURRENT HOU LY RATE. <br />EHD I <br />Rec ' <br />13- - <br />Titley <br />EHD 23-04 U <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />