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O.P0.0 (N• •.0 SAN JOAQUIN COUNTY c. ENVIRONMENTAL HEALTH DEPARTMENT -. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd cq�/koR�'�P &(5rvlk cwt UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: CW Inspection Date: lc� Facility Address: PA'\ P��, N Service Request #: '!8 vX-. 00 69Q D(�� Onsite Service Technician's Na e 0, m I C Service Technician/Installer Exp. Date: Manufacturer Training: - I b - iI&a-vu, ❑ line test programmed ❑ SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: • ' ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed ,, pl.Wga— sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: _ M� ❑ NA 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 `4[J Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other • ' Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS W ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi ,, pl.Wga— minutes S condary containment testing for: LIII Piping M� Sump(s) UST(s) s Tting for the above components are next due by: i. 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 Thisffljacifi is NOT APPROVIED tq operate M EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12 >I �� tt • ' f ! W Or C W a • ,, pl.Wga— iNo ��M' �UMAI M� M EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12