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OPa'UIN'•.0 ?' 'p SAN JOAQUIN COUNTY Q: •a ENVIRONMENTAL HEALTH DEPARTME. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 C`qC� oRa�P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name:I V /f( O A , I Inspection D te: Facility Address: j ''I ' ,( �p �1J�t/1 "v" Se�rvi%ce Request #: Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manuf c urer Tra ning: ❑ Leak detector ❑ SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ 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) XThis UST facility is APPROVED to operate SERVICE 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 ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) -Testing for the above components are next due by: Note: Please be aware that 21 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 ❑ This UST facility is NOT APPROVED to operate EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. pe r: eceived B a� Title: EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT