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O P'4 U 1 N• •.0 <br />_:• SAN .IOAQUIN COUNTY <br />Q. -+ ENVIRONMENTAL HEALTH DEPARTMENT <br />y. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />• �. P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Faci ity Name: <br />Inspection Date: <br />Y 0CA aa?) <br />15 —)A I <br />Facility Address: 14 <br />Service Request #: <br />3 1 CA- <br />3-- <br />Onsite Service Technician arae: <br />ICC Service Technician/Installer� Exp. Date: <br />Manufacturer Training: <br />`0)'t <br />❑ mechanical Model: <br />NOV-I- ?) I )o Iii 44 <br />SERVICE <br />Q o n e,Ov �LA-''S 4o2 +l; i or 40 <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 />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />Q o n e,Ov �LA-''S 4o2 +l; i or 40 <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 />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Title: <br />Secondary containment testing for: <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 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 />Other: see below 'S <br />❑ This UST facility is NOT APPROVED to operate <br />xve <br />Q o n e,Ov �LA-''S 4o2 +l; i or 40 <br />rev►�,O � i <br />seri `� � � �� <br />mcurN . <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD Inspect <br />Received By: , <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />6410 <br />UST SERVICE REQUEST INSPECTION REPORT <br />