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SAN JOAQUIN COUNTY <br />Ile ENVIRONMENTAL HEALTH DEPARTMENT <br />110: <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 to - <br />Qi Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sagov.org/ehd (�/f�i o- <br />CjFpRN% <br />I I.30aw <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: E]0,1(2,,n <br />Facility Address: <br />Onsite Service Technician's Name: ICC Service Tech <br />,,St6rqt n <br />SERVICE <br />,a P 121 g C? <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY 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 />odel:❑ <br />Elelectronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />❑ This UST facility is APPROVED to operate <br />on Date: <br />ra - <br />Service Request #: <br />Aaller Exp. Date: Manufacturer Training: <br />SERVICE <br />,a P 121 g C? <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY 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: '�Dp_s c. <br />170 psi <br />_U5 minutes SCS tort_ <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 />❑ <br />Other: see below <br />`gyp This UST facility is NOT APPROVED to operate <br />110i 4 Aosi <br />,a P 121 g C? <br />(�A4Z a4CLU Pzt"_MLU � aati <br />CLLAd �)a�:AA <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD InspeRece <br />- 1 - a 0)� 11 ", <br />i�ttad By: ���-- <br />^r L_ <br />Title: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />