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UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />()A Avi, <br />Inspection Date: <br />G <br />SAN JOAQUIN COUNTY <br />r�-4 <br />N I { <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />��1POR� <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />❑ line test programmed <br />❑ <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />()A Avi, <br />Inspection Date: <br />Facility Addre s: <br />3� 4 v TA <br />Service Request #: <br />by 6 <br />Onsite Service Technician's Name: <br />ICC Service Technician/Ins aller Exp. Date: <br />Manufacturer Training: <br />THIS FACILITY IS SUBJECT TO REINSPECTION, AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />SERVICE <br />rf <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS 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 />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />X, <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 />rf <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS 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 f ► p,Y1cz �'►i bW1 {—�r►St i i:rl SvvVr! p <br />-- minutes }a TrUc:� Si clisr ,ts 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 />Note: Please be aware that 21 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 />X, <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />i` Sd .+yt4L+V—�'`� Gl <br />rf <br />'° 4�S Vl i i C� ►S <br />iS �' <br />THIS FACILITY IS SUBJECT TO REINSPECTION, AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD In t <br />RP eived By: `,j <br />Title: <br />sib ,-e <br />END 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 ti� <br />