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102 <br />U. 1. c <br />SAN JOAQUIN COUNTY <br />c: -+ ENVIRONMENTAL HEALTH DEPARTMENT <br />X116 �X 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s4gov.org/ehd <br />q�%i=ijRa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Leak detector <br />Inspection Date: <br />❑ mechanical Model: <br />�)I� <br />04 C& <br />Facilit ddress: <br />❑ <br />Leak detector <br />Service Request #: <br />❑ mechanical Model: <br />ire ,Q t-4 1tVe a- <br />❑ electronic Serial #: <br />❑ <br />Onsite Service Tec <br />ician's Name: <br />ICC Service Technician/installer Exp. Date: <br />Manufacturer Training: <br />❑ positive shutdown Model: <br />EHD Inspe or: <br />❑ fail safe Serial #: <br />P� -0) e a <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />ire ,Q t-4 1tVe a- <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />EHD Inspe or: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />M70ther: <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 />This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />b�ea.�e e <br />❑ Caldwell System ❑ Other <br />ire ,Q t-4 1tVe a- <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />EHD Inspe or: <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 />M70ther: <br />see below ` <br />❑ This UST facility is NOT APPROVED to operate <br />IA <br />ERev 2HD 230/12 ll�`Nl3-04 P� (fie �� -1 UST SERVICE REQUEST INSPECTION REPORT <br />— e �� �1►v� pus <br />UoV'6 on`� 'o u v <br />ri co lu r .lRa <br />M l �V <br />c 0 (kQ e,.-4 -- <br />b�ea.�e e <br />WWi Qvv <br />ire ,Q t-4 1tVe a- <br />wt awV1e V <br />, xt <br />MT�!4 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'6 CURRENT HOURLY RATE. <br />EHD Inspe or: <br />Received By: <br />/ <br />Title" <br />IA <br />ERev 2HD 230/12 ll�`Nl3-04 P� (fie �� -1 UST SERVICE REQUEST INSPECTION REPORT <br />