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A?''qu l�'• C <br />�• ' •p SAN JOAQUIN COUNTY <br />e ENVIRONMENTAL HEALTH DEPARTMENT <br />y ` 600 East Main Street, Stockton, CA 95202-3029 <br />4• �::P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />�IF0. <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility _Name: <br />- l� _ <br />Inspection Date: <br />❑ <br />❑ mechanical Model: <br />is �. �`<<-% <br />Facility Address: <br />•-� - -/ <br />Service Request #: <br />❑ <br />Leak detector <br />❑ <br />Onsite Service Technician's Name: <br />ICC ervice Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />SERVICE <br />- l� _ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />is �. �`<<-% <br />❑ electronic Serial #: <br />•-� - -/ <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 />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <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 />- l� _ <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />is �. �`<<-% <br />❑ Caldwell System ❑ Other <br />•-� - -/ <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 />THIS FACILITY 1S.SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Note: Please be aware that 21 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 />,!"tel � �-rr',.� L,`. ... _ <br />- l� _ <br />:'%i'�•� : ��r <br />r. v+'7 �� ���.. ,�c�.' 4� . <br />U ,�- -p- _ �<• <br />is �. �`<<-% <br />-s C'Y <br />•-� - -/ <br />re I IGf1 S, <br />THIS FACILITY 1S.SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspecior' <br />Received By: <br />Title: <br />EHD 23-b4 ?' <br />Rev 10/06%10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />