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/A4u t `c� SAN JOAQUIN COUNTY <br />Q ! ENVIRONMENTAL HEALTH DEPARTMENT <br />tn: < <br />t 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />- Telephone: (209) 468-3420 Fax; (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />T ► vet ossa <br />F-Txx-A <br />Inspection Date: <br />C1 / 2 r / .2j -D n <br />Facility Address: <br />❑ mechanical Model: <br />Service Request #: <br />Onsite Service Technician's Name: <br />Nt7 i Gii C <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />{iitl -)1 c M dLkJ <br />SERVICE <br />_ �_ <br />otliwaN U4 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />X111(. ' <br />❑ electronic Serial #: <br />Nt7 i Gii C <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />{iitl -)1 c M dLkJ <br />❑ electronic Serial #: <br />jj1A N i o � OG 'Vf -OAAYVQ. <br />❑ line test programmed <br />OY' Nt�u✓ S�c1 <br />sensor <br />— <br />❑ positive shutdown Model: <br />EHD Inspector: <br />f �IC1i�i� <br />❑ fail safe Serial #: <br />Received By: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />` <br />I ❑ fail safe Serial #: <br />ElNA <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 />otliwaN U4 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />X111(. ' <br />❑ Caldwell System ❑ Other <br />Nt7 i Gii C <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />{iitl -)1 c M dLkJ <br />Primary piping testing at: <br />psi <br />jj1A N i o � OG 'Vf -OAAYVQ. <br />(,fit"7 minutes <br />OY' Nt�u✓ S�c1 <br />Secondary containment testis for: <br />UDC(S) -0(- , ipir:g <br />cl1 Con -, r <br />Sump(s) UST(s) <br />EHD Inspector: <br />f �IC1i�i� <br />Testing for the above components are next due by: <br />Received By: <br />Note: Please be aware that 2° containment components are required to be tested upon <br />ins at,6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />011 `�lfd +) V4AfNC-<-)&(A „1 �� gist <br />_ �_ <br />otliwaN U4 <br />,� 1 l <br />i ) <br />M d+'l e r <br />X111(. ' <br />. , S �� 1� � i <br />Nt7 i Gii C <br />a - fzA. fyj" u v&s -4 <br />{iitl -)1 c M dLkJ <br />i r f M -16 e <br />jj1A N i o � OG 'Vf -OAAYVQ. <br />-Tht;1 Dr�u 1NdaCA ' \� <br />OY' Nt�u✓ S�c1 <br />(A� �i . L <br />cl1 Con -, r <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY T ME A END'S CURRE T HO RL ATE. <br />EHD Inspector: <br />f �IC1i�i� <br />�L �I�U <br />Received By: <br />ILC,�SE'YV1C <br />TFl: <br />�"techniUcl�► <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />