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-E •o SAN JOAQUIN COUNTY <br />NVIRONMENTAL HEALTH DEPARTMENI <br />1868 East Hazelton Avenue, Stockton, CA 9520 - 232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ORS <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />-fo \,"! (A'_. v <br />Inspection Date: <br />❑ <br />❑ mechanical Model: <br />84 114 1 eZ 1 <br />Facility Address: <br />Gt �7E'S`150 i <br />Service Request #: <br />--T-Yz ,i� carn <br />'d McgvAe cc,. <br />`sz 0,066L q3 <br />Onsite Service Technician's Name: <br />ICC ervice Tec hnician/Installer Exp. Date: <br />Manufacturer Training: <br />*a Ae, <br />9 --i - zc <br />Task14 j4-8 - /s - <br />SERVICE <br />-fo \,"! (A'_. v <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />c ' ti1 f <br />❑ electronic Serial #: <br />Gt �7E'S`150 i <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />w <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />40 PO <br />CtI3ry,[av sensor .6--oUeseaAW r <br />Q nr vi aQ <br />❑ positive shutdown -Model: <br />❑ fail safe Serial #: <br />Y" V", f Olf'_T_MrnCdtAeW <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />EHD Inspector: <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 />IN <br />SERVICE <br />-fo \,"! (A'_. v <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />c ' ti1 f <br />❑ Caldwell System ❑ Other <br />Gt �7E'S`150 i <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />w <br />Primary piping testing at: <br />❑ <br />psi <br />40 PO <br />minutes <br />Q nr vi aQ <br />Secondary containment testing for: <br />UDC(s) Piping <br />Y" V", f Olf'_T_MrnCdtAeW <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 2° 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 />O4tSi te, <br />-fo \,"! (A'_. v <br />- <br />� <br />�e�- <br />- <br />c ' ti1 f <br />L <br />1r�i i �E "fes 1 ,J <br />Gt �7E'S`150 i <br />�St? r1 rl�C. �- 4-0 <br />w <br />40 PO <br />L" m <br />Q nr vi aQ <br />5W0A <br />Y" V", f Olf'_T_MrnCdtAeW <br />Q r0 <br />kdY <br />SOV' `� <br />A <br />P- iCO-d <br />O s <br />i Cpt (�1 <br />THIS FACILITY IS SUBJECT TO <br />REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY <br />RATE. <br />EHD Inspector: <br />y� <br />Y P,a t_L <br />Reoei d By: <br />L,44--- <br />Title, <br />;:/ <br />`'��� <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />