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SAN JOAGIUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sagov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Na e: <br />�f <br />Inspection Date: <br />Facility AdTress: <br />C <br />Service Request #: <br />Onsite Service Technician's Name: ` <br />�, I <br />ICC Service Te hnician/Insfaller Exp. Date: <br />Manufacturer Trains g: <br />SERVICE <br />VOAoinn <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Rec ed By: <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <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 />VOAoinn <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 />, i�\ c 1 <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />Rec ed By: <br />minutes <br />Titl <br />Sec ndary ontainment testing for: <br />)UDC(s) Piping <br />' Sump(s) _ UST(s) <br />Testing for the above components are next due by: <br />t,5 <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />This UST f`cility is NOT APPROVED to operate <br />Vt 1Gi`iQ +0 <br />VOAoinn <br />.124 ref 1 eel' iC <br />1 a' v� <br />r <br />, i�\ c 1 <br />THIS FACILITY IS SUBJECT TO REINSPECTION <br />AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD Inor: <br />Fa tP)armsc)-, <br />Rec ed By: <br />Titl <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />