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o.PaU I N• •.c <br />?• �E •o� SAN JOAQUIN COUNTY s <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />N: <br />-. 186u cast Hazelton Avenue, Stockton, CA 9520u-0232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />q i 6 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Vi <br />E_ L_J ' S ?L r <br />li l _�_// 2 - <br />Facility Addre <br />: <br />Service Request #: <br />❑ <br />Leak detector <br />❑ <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />917 <br />� <br />-3)2 <br />fk -7 /-? <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THISFACILITY 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 />/•�'1n� �� sensor <br />Elpositive shutdown Model. `%Lf3Fro'344 <br />❑ fail safe Serial #: 9 2-9 4-39 <br />Rf' A <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THISFACILITY 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 />Sumps) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 21 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 />L -5 fAscel <br />Cti I— Ln 21W Bc h le- <br />eTHIS <br />THISFACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspe <br />pIf 7 <br />RA�yo_ ed B : <br />Title: <br />E (/ c _J <br />HD 23-04 <br />Rev 4/30/1 <br />UST SERVICE REQUEST INSPECTION REPORT <br />