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?' •o SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />y�Y 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />q�iFOR�'� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />SERVICE <br />//� / <br />yLJ��J./ <br />tw <br />Inspection Date: <br />VCL,&ry <br />❑ mechanical Model: <br />sir I -L <br />Facility Address: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Service Request #: <br />Z) 0 C y/ <br />�J <br />{ <br />Cl <br />Sri—coC C SZ1 r� <br />16YL4 <br />I <br />❑ electronic Serial #: <br />Onsite Service Technician's Name: <br />ICC Seryce T hnician/Installer Exp. Date: <br />h 1�I, l� f -p .-� <br />Manufacturer Training: <br />L v✓' <br />Ve-P ° c la. - 301/2 - <br />y lZ <br />❑ positive shutdown Model: <br />SERVICE <br />//� / <br />yLJ��J./ <br />tw <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 />sensor <br />❑ <br />❑ positive shutdown Model: <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 />//� / <br />yLJ��J./ <br />tw <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 <br />minutes <br />Secondaryne ting or: <br />Piping <br />Sum (s) UST(s) <br />9- Ta +,f d <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 />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />!J e4l WAA,,l Giti LGL 14117 144- 'f ^ 61 <br />�n _� <br />//� / <br />yLJ��J./ <br />tw <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />I 4- <br />Rec ' ed By: <br />,le- _-, <br />EHD 23-04 ' UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />