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°PautN 'P SAN .JOAQUIN COUNTY <br />a a ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />` Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />A��FOR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: � <br />Inspection Date: — <br />FacilityAddress: <br />ServiC5 Request <br />Onsite Service echnician's Name: <br />ICC Service Technician/Instal er xp. Date: <br />Manufacturer ini <br />❑ line test programmed <br />❑ <br />SERVICE <br />NEW; <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />`� �� �' �- �l • �r ' <br />❑ electronic Serial #: <br />❑ <br />line tet programmed <br />- <br />nsor <br />❑ positive shutdown Model: VIE 42-0 <br />❑ fail safe Serial #: <br />❑ NA <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 />❑ 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 />NEW; <br />Spill bucket Inimum 5 gallon <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 />`� �� �' �- �l • �r ' <br />Primary piping testing at: <br />❑ <br />psi <br />- <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />El <br />�/ 1/�� <br />Testing for the are 1i'�Sc du by: <br />above comp rite <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 facility is NOT APPROVED to operate <br />wim-s!1111 RX. <br />NEW; <br />X I r,u_►1/ N Vi : .�12111111"M�.Ifl Ill <br />[WI '' My �. ( .�_>,� r .' ' ill .Ill �� i_ <br />`� �� �' �- �l • �r ' <br />.. <br />Eh_. <br />- - : _. <br />d <br />- <br />EHD 23-0 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />