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o.P4� � N• •.c <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />in: <br />I < <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />c• P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siclov.org/ehd <br />i po <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name:Inspection <br />QD01I <br />Date: <br />Leak detector <br />❑ <br />Facility Address: <br />Service Request #: <br />❑ electronic Serial #: <br />�5kw 11-b4z' <br />Onsite Service Tech nician's_N e: <br />rccS rvice Technician/Installer Exp. Date: <br />Manufacturer Training: t- <br />PJA III <br />3 - - � 16 <br />1 &'RN" o- /�-; - I b A b I KLL L4 '),3 - <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />ff <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />1EHD <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />ff <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />�' I��N <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />M 10 <br />Secondary containment testi g for <br />UDC(s) C Piping <br />Sump(s) UST(s) <br />1EHD <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />This UST facilit is NOT APPROVED to operate <br />dl imps C-1 ( +0 2k-� <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />ff <br />fIXM- t <br />�' I��N <br />ON, <br />M 10 <br />r <br />1EHD <br />Insp$,�j:'eMo <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />