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OtgUv C <br />..�_�' •p� SAN JOAQUIN COUNTY <br />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 />atiFaRia <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Leak detector <br />❑ <br />Facility A res� <br />&TN4 P -j <br />Servicest #:-Ib� <br />L,S D 1 <br />44 <br />Onsit S ice Technician s Name: <br />`I <br />ICC Service Technician nstaller Exp. Date: <br />Manufacturer Training, -� <br />1 j T7-��: CB <br />JL <br />SERVICE <br />NWN, -W, <br />II � ��tL�I► � /_. � I� � J , wJ_,,`I .hula -1 isal/ �'_ .� <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Irmo /1. 1 = 2 <br />❑ electronic Serial #: <br />�II1E <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />. Into <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 />❑ fail safe Serial #: <br />❑ NA <br />❑ <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 />NWN, -W, <br />II � ��tL�I► � /_. � I� � J , wJ_,,`I .hula -1 isal/ �'_ .� <br />Spill bucket ❑ minimum 5 gallon <br />/.� ■ /.I ■ i J 1�. <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Irmo /1. 1 = 2 <br />`Caldwell System ❑ Other <br />�II1E <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />. Into <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 />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑. <br />Other: see below <br />Ix.This UST facility is NOT APPROVED to operate <br />■ �t - ri ►/II L f i !, . �,.2 I sire .1I /..E TW :fi _, ;. , . <br />NWN, -W, <br />II � ��tL�I► � /_. � I� � J , wJ_,,`I .hula -1 isal/ �'_ .� <br />_.� <br />Ky. W III L G R N �I <br />/.� ■ /.I ■ i J 1�. <br />A d ��f L� <br />Irmo /1. 1 = 2 <br />t l l _ <br />�II1E <br />. Into <br />- <br />won g— <br />EHD 23-04`Z7 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />