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E <br />11 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street Stockton, CA 95202-3029 <br />Telephone: (209) 408'3420 Fax: (209) 468-3433 Web: www.sigov.orgish <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Fame: Inspection Date: <br />Ua letir C;p 24- 7 <br />Facility Address: Service Request#: <br />'Lpo <br />ro-nsite service-Techniclarfs Name. [CC Service TechnWanlinstaller Exp. Date: Ilfenufacturer Tra n ng: <br />of <br />SERVICE <br />Leak detector <br />❑ <br />0 mechanical Model: <br />milJd <br />0 electronic Sed al&. - - <br />0 line test programmed <br />❑ <br />Leak detector <br />F1 <br />0 mechanical Model: <br />0 electronic serial <br />El <br />0 line test programmed <br />sensor <br />El <br />0 positive shutdown Model: <br />EHD Inspector: y i <br />0 fall safe Serial #: <br />Received 1311 <br />11 NA <br />sensor <br />❑ <br />0 positive shutdown Model: <br />0 fall safe Serial P <br />❑ <br />• NA <br />01 <br />sensor <br />13 <br />0 positive shutdown Model: <br />• Nit safe Serial V. <br />El NA <br />0 <br />Drop tube with mechanical OV14fill at 95% <br />0 <br />Drop tube with mechanical overfill at 95% <br />11 <br />Overfill prevention (see LG letter 150-1) <br />11 <br />This UST facility Is APPROVED to operate <br />SERVICE <br />— Spill bucket 1:1 minimum 5 gallon <br />El <br />01 hour hydrostatic 0 Incon TS -STS <br />milJd <br />0 Caldwell System 0 Other <br />- Spill bucket 0 minimum 5 gallon <br />❑ <br />111 hour hydrostatic 1:1 Incon TS -STS <br />0 Caldwell System 0 Other <br />Primary piping testing at: <br />El <br />psi <br />minutes6- <br />N <br />Secondary containment testing fo <br />EHD Inspector: y i <br />!F Z L� UDC(s) iAr: 17 Piping <br />Received 1311 <br />UST(s)- <br />Testing for the above components are next due by: <br />NOW Prom be 8"PA thmt 9' L"NO fequk'ed to be tesbad upon <br />indw1aun, a months afbai, &W every 38 months thermfler. <br />❑ <br />Cold start of monitoring panel <br />01 <br />corrosion protection <br />11 <br />1 other: see below <br />0 This UST facility Is NOT APPROVED to operate <br />EHD 23-04 <br />Rev iataehoe/ <br />UST SERVICE REQUEST INSPECTION REPORT <br />Syr' r <br />milJd <br />THIS FACIUTY'IS SUBJECT TO RE;NSPECtION AT ANY TIME AT EHO'S CURRENT HOURLY RATE. <br />EHD Inspector: y i <br />Received 1311 <br />EHD 23-04 <br />Rev iataehoe/ <br />UST SERVICE REQUEST INSPECTION REPORT <br />