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O.P0.uIN• C <br />SAN JOAQUIN COUNTY <br />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 />A��FOR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />a)"0 <br />avp our a <br />Ip-3k=2101Li <br />Facility Address: <br />1-( L L� 1 �cC �" (,�-IL Sbpp,4-1 <br />Service Request #: <br />opo (0-o <br />Onsite Service Technician's Name: <br />ICC Service Technician/installer Exp. Date: <br />Manufacturer Training: <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />ca y -a l U30-:5 cx. <br />❑ electronic Serial #: <br />id <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor anY1 <br />El—posifiive shutdown Model: Oq <br />❑ fail safe Serial #: I ons 6-25 <br />T <br />AIf <br />lk <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />ca y -a l U30-:5 cx. <br />❑ Caldwell System ❑ Other <br />id <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 />❑ <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 />O 1Ae -6 very ' <br />0 1r 1Ct <br />9 r.Pi-Se-"-jt " S4 I <br />ca y -a l U30-:5 cx. <br />1$ 3.14 "7e6AQ-6 owJilc <br />id <br />THIS FACILITY IS SUBJECT TO REINSPECTI <br />N AT ANY TIME A HD'S CURRENT HOURLY RATE. <br />EHD I tor: <br />Received <br />Title: <br />,0l LIT <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />