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P LL <br />�o..co <br />SAN JOAQUIN COUNTY _. c�i <br />*ENVIRONMENTAL HEALTH DEPARTMENT <br />y _ X 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />�qLI F'ORN`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />o f 1ST t e- - rlI ,+e •--1,L) ��krn, <br />Facility Name: <br />cck y <br />Inspe ion D te: <br />-4 1 U <br />Facility Address: <br />Ck <br />Service Request #: <br />s f 00)56(43 4 <br />Onsite Service Technician's Na 10C Service T nicianflnstaller Exp. Date: <br />i" �� 11 � 3-5- <br />Manufacturer Training: Goa,'H <br />U -J.-1 —1 NM o- <br />SERVICE <br />�ear <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />mid e <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />v� <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />THIS FACILITY <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />By <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 />This UST facility is NOT APPROVED to operate <br />•I <br />�ear <br />Spill bucket ❑ minimum 5 gallonhour <br />mon-V C'Nv\ <br />flSERVICE <br />hydrostatic ❑Incon TS -STS <br />al , <br />dwell System Other ckaay� VOSLV-e-- <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 />mid e <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 />v� <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 <br />�ear <br />-Aax-4 01 <br />mon-V C'Nv\ <br />V,)e,'l V•ex'► h o <br />ro <br />+10 yV(2 <br />r -Q <br />mid e <br />-6e4;, uip <br />' <br />v� <br />r <br />l,u <br />ryu, r <br />THIS FACILITY <br />IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S cU_RRENf HOURLY RATE. <br />EHD Inspec <br />Recei <br />By <br />Title: <br />X tf L <br />EHD 23-04'_� v UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12p OLS <br />I � � o, <br />