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oPqu IN••.0 �.• ,�� .o SAN .lOAOUIN COUNTY Q. �+ ENVIRONMENTAL HEALTH DEPARTMENT N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd FORa\P UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUES NSPECTION R PORT :C�� k, Facility Name: Insp'b0ion Date: V 2 �3 ' 02 I — 2 Facility Address: Service Request #: 3 oh G +lll it -NI ,� Onsite Service Te1cAhn►ician' N me: ICC S/ rvice Technician/Installer Exp. Date: Manufacturer Training: 2 L��,�— 4l, vV� 4-(O I UR- .�- -)—IG SERVICE Leak detector ❑ ❑ mechanical Model: • ❑ electronic Serial #: +lll it -NI ,� ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: _ El ❑ line test programmed ►� i ,• • , sensor may( positive shutdown Model: '?,Q g gfail safe Serial #: s UST(s) PO 4 PinA sensor I f ❑ positive shutdown Model: ❑ ❑ fail s fe Serial #: ❑ NA WQ ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 950'0 ❑ Overfill prevention (see LG letter 150-1) SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS • ❑ Caldwell System ❑ Other +lll it -NI ,� Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary Primary piping testing at: El ��Sa. ►� i ,• • , minutes -J �c,onda containment testi g for- "� `SUm UDC(s) � P� Piping s UST(s) PO Te ting for the above components are next due by: Q Note: Plea=_e be aware that 20 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 Rev 4/30/12 0 A ION tax* oh"W --=21mmmomt ra •• i ►Ell I 9ffl_`�• vo� • 1 ► +lll it -NI ,� i mff• , • 'moMIN, [P'. " : ' ��Sa. ►� i ,• • , • s Milli! anown" Poll MIA • . -•WA VMO�VA'§M%-4,= Rev 4/30/12