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o,?'•q� I N• c <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6!>>32 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.org/ehd <br />A��FOR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Ll 0 <br />Leak detector <br />Inspection Date: <br />❑ mechanical Model: <br />g � <br />❑ electronic Serial #: <br />Lzs IIZ <br />Facility Address: <br />❑ <br />Leak detector <br />Service Request #: <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />Onsite ServiceTechnician's Name: <br />I= Service Technician/Installer Exp. Date: <br />Manufacturer Training: may► <br />IJ <br />(� e �✓�.1 <br />S-1 1 Z 1 13 <br />1 tilt -- Q-41?, <br />u <br />SERVICE <br />Ll 0 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />�D <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 />i� <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />X <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 />ISI This UST facility is APPROVED to operate <br />SERVICE <br />Ll 0 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />�D <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 />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 />i� <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />X <br />Other: see below File " D <br />❑ This UST facility is NOT APPROVED to operate <br />Uri ► atl s-!' ui)L a -el a <br />Ll 0 <br />�D <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />I Receive <br />T'tle: <br />EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />