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;'CL <br />SAN <br />C <br />'' •o SAN JOAQUIN COUNTY <br />' <br />OENVIRONMENTAL HEALTH DEPARTMEN . <br />i`. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />. 0- <br />Facility Address: Service Request #: <br />rDte." EJ' �JstI2—I <br />Onsitb S rvice Technician s Name I ICC Service Techni ianllnstaller Exp. Date: Man ufac ured Training: <br />F y b Mw is elbsl/ <br />SERVICE <br />J . ■ it I ►+ , r �L <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />electronic Serial #: <br />_ <br />THIS S SUBJECT TO <br />❑ line test programmed <br />❑ <br />psi <br />l <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />LJ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />O positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />XI <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />rEl <br />Overfill prevention (see LG letter 150-1) <br />This UST facility is APPROVED to operate <br />SERVICE <br />J . ■ it I ►+ , r �L <br />`� Spill bucket minimum 5 gallon <br />1 hour hydrostatic ❑ Incon TS -STS <br />al wII System q,Other <br />par <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />_ <br />THIS S SUBJECT TO <br />Primary piping testing at: <br />❑ <br />psi <br />l <br />minutes <br />Secondary containment testing f r•P(X�'1 G fk-iAD <br />UDC(s)�jl Piping <br />mp(s) T s) <br />j��br <br />T com�o�nen s rae ndxtt�uy: <br />stabove <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 />Cold start of monitoring panel <br />LJ <br />Corrosion protection <br />❑ <br />Other. see below <br />❑ This UST facility is NOT APPROVED to operate <br />• <br />I�.f li ,IT..lr i `,� -� 111 .�' <br />J . ■ it I ►+ , r �L <br />_ <br />v <br />r — - <br />'7 <br />_ <br />THIS S SUBJECT TO <br />.� , -. <br />.,-i. <br />I <br />l <br />9 <br />EHD 23-04 V / UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4130/12 /J <br />