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NqLVI.ty <br />'' <br />40 <br />?' O� <br />SAN JOAQUIN COUNTY <br />2 ^� <br />Y. <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />• <br />gGii=ijRd <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 me: <br />Vo-livo Ruick <br />Inspection Date: <br />- <br />Leak detector <br />1-110 I <br />Facility Address: <br />1 o,Q c o out. <br />Service Request #: <br />n 8 6 <br />Onsite Service Tec nician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ <br />Leak detector <br />I V - Q -a,6-6, vo-- x-30 <br />SERVICE <br />E2, "If ATW�nll?lff =16"WAUM <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />II 1_. . • <br />❑ electronic Serial #: <br />•�I► • U t �' <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <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 />E2, "If ATW�nll?lff =16"WAUM <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />II 1_. . • <br />❑ Caldwell System ❑ Other <br />•�I► • U t �' <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) Piping <br />Sump(s) UST(s) <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 />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />' .I • 1 '_�. .�. • • • <br />E2, "If ATW�nll?lff =16"WAUM <br />A911 <br />t t ! <br />II 1_. . • <br />�„ • , ��• • <br />•�I► • U t �' <br />MR1EMMA <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. mi <br />EHD IrUctor: <br />Iff-PAOL• <br />Received By: <br />K <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />