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UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />SAN JOAQUIN COUNTY <br />Imo` 2t <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />322G2. <br />-4//67//4 <br />9i1FGR�� <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si4ov.org/ehd <br />. <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />r o 4 t" e <br />Inspection Date: <br />--Even NQ. <br />322G2. <br />-4//67//4 <br />FacilityAddress: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Service Request*: <br />23,64 W. Gr <br />L'- "- <br />SR DU174:3 '71 <br />Onsite Service Technician's Name: <br />Scat &0-0, <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />1 <br />0-. 3 <br />o H1 t <br />SERVICE <br />r o 4 t" e <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 />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />C' This UST facility is APPROVED to operate <br />SERVICE <br />r o 4 t" e <br />% Spill bucket L11'mminimum 5 gallon <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 />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 20 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 />,� — <br />r o 4 t" e <br />I 11 {� 1� <br />&nj 11 4 , h 'Y <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />Re By: <br />" <br />Titley ) s <br />EHD 23-04 <br />Rev 4/30/12 <br />II <br />UST SERVICE EQUEST INSPECTION REPORT <br />