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...__•y-n:::.�...-.•.,-..:....rs•:.. -.:`i::'�:r:. rein„'":r�. ...•S! •:- _ __ <br />J'i. .. �'w Y•:_ . ::1 �. ... '. Pn ::i�J�:�S c7'`)•' •`:'7r. N':•.Ci'J :.t'v ::"V?y '—k:, .Y•T>;�RM.. , <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />. Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.ora//ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Facility Address: Service Request #: <br />Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp. Date: Manufacturer Training: <br />'� fr y' '” ' J'I E. ,F", c� .kb4wh— <br />SERVICE <br />,1pit! <br />Leak detector <br />® <br />❑ mechanical Model: <br />){4\ _. tfl: iJ•y:�'i•i'cK <br />❑ electronic Serial #: <br />a<?Y"l <br />❑ line test programmed <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 />sensor <br />0 <br />❑ positive shutdown Model: <br />TIME AT EHD'S <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 />,1pit! <br />bucket ❑ minimum 5 gallon <br />pITI <br />hour hydrostatic ❑ Incpn TS -STS <br />){4\ _. tfl: iJ•y:�'i•i'cK <br />❑ Caldwell System C`kOther <br />a<?Y"l <br />` ( Spill bucket ❑ minimum 5 gallon <br />a 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 />Secr: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />-Testing for the above components are next due by: <br />1 <br />TIME AT EHD'S <br />Note: Please be aware Qmt 2'containment components are reqused to be tested upon <br />fnstaflation. 6 monft aft. end evmy 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ I <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />'" 1 f e, 4FMdP' <br />s_ <br />at,Z•f � 1n <br />ar` 41 '�'t•- <br />-'�� C. iM 'a �R '�:•n �3 r r <br />.'�i '�JY� i'C,'.'f+�'e j?'�i <br />){4\ _. tfl: iJ•y:�'i•i'cK <br />•' l'•�•li, <br />a<?Y"l <br />THIS FACILITY IS SUBJECT TO REINSPECTIO AT fflff <br />TIME AT EHD'S <br />CURRENT HOURLY RATE, <br />EHD Insp '` <br />Re 11,1' <br />EHD 25-04 <br />Rev 4/50112 <br />II <br />UST SERVICE REQUEST INSPECTION REPORT <br />