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,�yy fifinn REC� SAN JOAQUIN COUNTY +;G ENVIRONMENTAL HEALTH DEPARTMENT 2,0'',' /r .;X 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov�rp/et��i „3N. ,,,- NTAL HEALTH JNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INS I EXPORT Facility Name: Inspection Date: L CJS t r GS "i S t� 1 Facility Address: Servide Requ st #: 1q01 S. 61 to SRoo-76qIW Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: na a l7lS- I &tinti Od L07 02® SERVICE Spill bucket El minimum 5 gallon Leak detector ❑ ❑ mechanical Model: ❑ Caldwell. System ❑ Other ❑ electronic Serial #: Spill bucket ❑ minimum 5 gallon ❑ line test programmed ❑ 1 hour hydrostatic ❑ Incon TS -STS Leak detector ❑ ❑ mechanical Model: Primary piping testing at: El electronic Serial #: psi ❑ line test programmed minutes sensor ❑ ❑ positive shutdown Model: 3 UDC(s) Piping ❑ fail safe Serial #: Sump(s) UST(s) ❑ NA Testing for the above components are next due by: sensor Note: Please be aware that 21 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ positive shutdown Model: Cold start of monitoring panel ❑ fail safe Serial #: Corrosion protection ❑ NA Other: see below l ®YIYCf 'aYl tAW! sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) ❑ This UST facility is APPROVED to operate f This UST facility is NOT APPROVED to operate Oki siiC t'b olerYC CDnr iovl .set Spill bucket El minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS -es 1-), Y"q ar V DL VCY ❑ Caldwell. System ❑ Other u Spill bucket ❑ minimum 5 gallon El ❑ 1 hour hydrostatic ❑ Incon TS -STS rel ❑ Caldwell System ❑ Other he F] me yo Primary piping testing at: ❑ psi t(�P / f E g I /+ e1�'�'rl epi` I v ;Yl ee b" V't minutes 1 I no Secon ary containment testing for: ,'3 st�et� liodbd 0 b -S e rV 3 UDC(s) Piping Irig 6f Sump(s) UST(s) Testing for the above components are next due by: Note: Please be aware that 21 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection Other: see below l ®YIYCf 'aYl tAW! This UST facility is NOT APPROVED to operate Oki siiC t'b olerYC CDnr iovl .set r >Me hS�Ul, crn r orl IytrrlLrll -es 1-), Y"q ar V DL VCY rA1512 n arjlrint oy4AIllyi u UDC, ah r e- i I i e✓n of W re, Ce S1,11-7Pere m rel a ,1, /It a� he F] me yo m bout -Form n fi V II le a )', j neeall t(�P / f E g I /+ e1�'�'rl epi` I v ;Yl ee b" V't 1( t 1 I b ►Y1 1 7-4))n the. CJS) % 1 I no - Ui ,'3 st�et� liodbd 0 b -S e rV n nrnen f es Irig 6f U L 3 .fCJ ®he- h --r/r ZiY<571ro )6j? t L �J THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. ector: Received By: Title: tj vt AD 23-04 UST SERVICE REQUEST INSPECTION REPORT av 4/30/12