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oP4ui� c <br />?' -�'' SAN JOAQUIN COUNTY <br />Q: Z� ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />(•., _ �P <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />A�hi <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />c;' Ct C- C - V- S L <br />-r->e v 2 A Z O /.3 <br />Facility <br />Service Request4: <br />Address: ' <br />L-t-40 <br />(-3f-)- 006U <br />Onsite Service Technician's Name: <br />ICC Service Tec hnician/Installer Exp. Date: <br />Manufacturer Training: <br />�0c. <br />❑ mechanical Model: <br />V=-1 S <br />SERVICE <br />T1a.•� <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />r <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />�GY�wt-- <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />VIv% 5 <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />THIS F ILITY IS SUBJECT <br />❑ fail safe Serial #: <br />HD'S CURRENT HOURLY <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 />T1a.•� <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />r <br />❑ Caldwell System ❑ Other <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 />�GY�wt-- <br />minutes <br />.� <br />Secondary containment testing for: <br />UDC(s) Piping <br />VIv% 5 <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 />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />✓V" �'CI <br />T1a.•� <br />iii 7 - Y 'Iy <br />N <br />r <br />1 y c.�ir <br />1'1y <br />fXli� <br />�GY�wt-- <br />v�r�ir.c-S <br />.� <br />n.Jr <br />�.r <br />VIv% 5 <br />W S <br />-- <br />.� 'GI <br />t3 qLo —Ie; <br />VR -z0 <br />THIS F ILITY IS SUBJECT <br />TO REINSPECTION AT ANY IME AT <br />HD'S CURRENT HOURLY <br />hATE. <br />EH D t r:eceived <br />,,4�, <br />By:YCW <br />/ <br />Title: <br />EHD 23 - <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />