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• <br />O9''�U I N C <br />-'' p SAN JOAQUIN COUNTY <br />Q. 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�il= iiR��P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />) L'� <br />rOff -64 ALL <br />Inspection Date: <br />❑ <br />Tro <br />4 <br />JcaR�aq#: <br />IS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Facility Address: Ili <br />❑ <br />Leak detector <br />❑ <br />3 6It'd - Taot w <br />B) V&co8 <br />❑ electronic Serial #: <br />❑ <br />Onsite Service Technician's Name: <br />ICC Service TechniclaWhAtaller Exp. Date: <br />Manufacturer Training: <br />❑ positive shutdown Model: <br />v - <br />I MrA. *,71i7I41111WZ4 <br />SERVICE <br />) L'� <br />rOff -64 ALL <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />4 <br />❑ electronic Serial #: <br />IS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />c, A- sensor C L <br />14 V <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 />X This UST facility is APPROVED to operate <br />�--4FAka Wisner ; a�stw <br />SERVICE <br />) L'� <br />rOff -64 ALL <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />IS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 tri <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />u 9 <br />) L'� <br />rOff -64 ALL <br />_ L5 a <br />Ick <br />'' P[V S ANN" F4 i It14,614W <br />r Sc <br />IS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD In ct <br />/,J-. A t, A <br />Received B —,_ <br />I <br />Title: <br />EHD 23 a <br />T§ v1-1 <br />Rev 4/3 / ' v <br />UST SERVICE REQUEST INSPECTION REPORT <br />