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��a,..f' • pG <br />SAN JOAQUIN COUNTY <br />* ENVIRONMENTAL HEALTH DEPARTMENT <br />{ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />�a�il�pA�`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility N <br />Inspection Date: <br />Leak detector <br />❑ <br />Facility Address: <br />i 3< c ("3. M v\ �Af- <br />Service Request #: <br />S G <br />Onsite Service Technician's Name: <br />Soto <br />ICC Service Technician/Installer Ems. Date: <br />Manufacturer Training: <br />►moo <br />Leak detector <br />❑ <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />c) ns <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />�kc`llirw_;is <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />EHD Inspector: <br />❑ fail safe Serial #: <br />Received By: � <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 />c) ns <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />sb- <br />❑ Caldwell System ❑ Other <br />�kc`llirw_;is <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testin f r: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Te s ing for the above components are next due by: <br />THIS FACILITY &SI113JEctIrO REINSPECTION AT ANY TIME AT EHD'S CURRENT <br />�l'10 010 L 0 -I>takA-- <br />EHD Inspector: <br />Note: Please be aware that 2° containment components are required to be tested upon <br />Received By: � <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 />EHD 23-04 <br />Rev 4/30/12 <br />ilv <br />UST SERVICE REQUEST INSPECTION REPORT <br />, 1 SOCz_ A�t <br />UV att bipun <br />c) ns <br />5 LZsC, I ka:U r <br />0 Iry <br />CIOU C&60LA9P,� <br />sCOA4- )e <br />sb- <br />-s <br />�kc`llirw_;is <br />dtoN <br />IA,�-. <br />THIS FACILITY &SI113JEctIrO REINSPECTION AT ANY TIME AT EHD'S CURRENT <br />H URLY RATE. <br />EHD Inspector: <br />n <br />Received By: � <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />ilv <br />UST SERVICE REQUEST INSPECTION REPORT <br />