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O Pp•U I N•,.0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sagov.org/ehd qC/FpRN UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Tme: aw Inspect' n Da e: ❑ ❑ mechanical Model: Facili yf�A dr "ss _ p % Servicd Request #: ❑ Leak detector ❑ On sit Service Techni'an's; me: iccA—ervice Technician/I staller E p. D e: Manufacturer Training: VW, ❑ ON ij(,, el'i Pv7 /I SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: I� ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed e nu tensor ❑ positive shutdown Model: go IJq.� ❑ fail safe Serial #:yi �!A w sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) / This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other I� Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate EHD 23 v J�%� V UST SERVICE REQUEST INSPECTION REPORT Rev Rev 4/30/10/1 2 l" 40 I� • "Oh, I�AT EHD'S CURRENT HOURLYWEER 0 1 M��Mfiv EHD 23 v J�%� V UST SERVICE REQUEST INSPECTION REPORT Rev Rev 4/30/10/1 2 l"