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oPQ� I�••.c <br />SAN JOAQUIN COUNTY <br />Q'- ENVIRONMENTAL HEALTH DEPARTMENT <br />x 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />L <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />Facility Address: <br />10c65 <br />Service Request #: <br />&s3 v <br />❑ mechanical <br />Model: <br />Onsite Service Technician's Na e: <br />IICC gervice Technician/Installer Exp. Date: <br />Manufacturer Training: <br />PL tN,- L <br />x.- I t <br />�iIZ 1 <br />*This UST facility is APPROVED to operate <br />SERVICE <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ <br />❑ mechanical <br />Model: <br />Spill bucket ❑ minimum 5 gallon <br />❑ electronic <br />Serial #: <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ <br />❑ mechanical <br />Model: <br />❑ electronic <br />Serial #: <br />UDC(s) Piping <br />❑ line test programmed <br />Sump(s) UST(s) <br />sensor <br />Testing for the above components are next due by: <br />❑ <br />❑ positive shutdown <br />Model: <br />Cold start of monitoring panel <br />❑ fail safe <br />Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown <br />Model: <br />❑ fail safe <br />Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown <br />Model: <br />❑ fail safe <br />Serial #: <br />❑ NA <br />❑ <br />Drop tube with <br />mechanical overfill at 95% <br />❑ <br />Drop tube with <br />mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LIS letter 150-1) <br />*This UST facility is APPROVED to operate <br />SERVICE <br />• 5'�.- 1 , <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY CT 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 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 />E H D 23k-4 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/0 <br />• 5'�.- 1 , <br />- ie*l s <br />a O�jc n l,,//�� � 42 i3_211 <br />THIS FACILITY CT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins or <br />Receive <br />Title: <br />E H D 23k-4 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/0 <br />