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W.O.# NW1-2330385 <br />Cust Ref# : 19976.171775.5 <br />oAgU1N\ .• <br />SAN JOAQUIN COUNTY AN 4 2017 <br />i :�• <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />= Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.ora/ehd <br />1 <br />4`�� R% ieNVIRONMENTAL HEALTH <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPEcnom vWfillMk"3T <br />Facility Name: <br />Inspection Date: <br />❑ <br />❑ mechanical Model: <br />P Ii <br />Facility Aptheie: <br />Service Request # <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />Onsite Service Tectu ieWe4 Near: <br />ICC Service Technicianfins`ailer Exp. Date. <br />Manufacturer Training: <br />s is t t <br />❑ <br />❑ positive shutdown Model: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />P Ii <br />❑ electronic Serial _ <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 />El <br />❑ fail safe Serial #: <br />FOCorrosion <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <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 />'-❑ 1 hour hydrostatic ❑ Incon TS -STS <br />P Ii <br />❑ Caldwell System ❑ Other <br />i <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />'El 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 />EHD Inspector. <br />Ncfe: P�case Ge award Rut 7 containment wmpcnenL are rtxyirod to Ee teCed upon <br />in=1!abw, 6 months alter, and e y 36 —111 IhcreaNer- <br />❑ <br />El <br />Cold start of monitoring panel <br />FOCorrosion <br />protection <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />%� S <br />P Ii <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD Inspector. <br />Received By: <br />Title: <br />%� S <br />