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oAo•u I!y.•.c <br />SAN JOAQUIN COUNTY <br />Q. �+ ENVIRONMENTAL HEALTH DEPARTMENT <br />y.hu < <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s4gov.org/ehd <br />9�iFpRN <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />11 S (t <br />Inspection Date: <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPE�TIO AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />Facility Addres <br />Leak detector <br />Service Request #: <br />L/ ('CL <br />c , p1c <br />% <br />Onsite Service Technician's Name:ce <br />❑ line test programmed <br />Technician/In taller Exp. Date: <br />Manufacturer Training: <br />C-Deec, <br />❑ positive shutdown Model: <br />4C.S;;i — <br />1v�9 -i <br />SERVICE <br />11 S (t <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPE�TIO 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 />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />9 This UST facility is APPROVED to operate <br />SERVICE <br />11 S (t <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPE�TIO 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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />n 5 O i', <br />11 S (t <br />v �� fel ►� <br />cl <br />THIS FACILITY IS SUBJECT TO REINSPE�TIO AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />Rec e B gL L,,,jTitle: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPOF <br />Rev 4/30/12 <br />