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OpQ.V IIV• C <br />?'—+E'f'' �� • SAN JOAQUIN COUNTY <br />0:; ENVIRONMENTAL HEALTH DEPARTMENT <br />>'. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*gov.org/ehd <br />��FORa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />1 C-- <br />Inspection Date: <br />(0 � <br />Facility Address: <br />115Qq q W. �f CQ- l �b l ow <br />Service Request #: <br />�ZQO-41 ►7A <br />Onsite Service Technician's Name: <br />ICC ServiceTe�cian/Installer Exp. Date: <br />Training: <br />❑ <br />❑ line test programmed <br />rManufacturer <br />U U <br />Z <br />SERVICE <br />L�C <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />ataj r, oA a 6� <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />c V�," ef Ao't <br />❑ line test programmed <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 />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />Drop tube with mechanical overfill at 95% <br />EOverfill <br />prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />L�C <br />Spill bucket `minimum 5 gallon <br />1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell SystemOtherl <br />ataj r, oA a 6� <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 />c V�," ef Ao't <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 />��V <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 />Thi �Sjf cility is NOT APPROVED to op r to <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />l}y , <br />ataj r, oA a 6� <br />.. <br />r <br />1- 0 QQW r <br />Rr <br />UK Ana <br />c V�," ef Ao't <br />THIS FACILITY IS SUBJECT TO RRE�INSPECTION kT ANY TWErllkT <br />EHD'S CURRENT HOURLY RATE. <br />EHD In or. <br />��V <br />Received By: <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />