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/OAQU I <br />SAN JOAQUIN COUNTY <br />w { ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />-1 -'0- evi2,n <br />Inspection Date: <br />I Ll <br />Facility Adid�ress:-�j�(n� <br />Service Request #: <br />Onsite Service Technician'sName: <br />ICC Serv' In <br />a Technician/staller Exp. Date: <br />cturer Training:1_� 'liL_ <br />TW -v- <br />❑ line test programmed <br />❑ <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <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 />No "L <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 />❑ 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 />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 />No "L <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />�^^ <br />EHD Ins pe r: 2ma <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 />Other: see below jQ <br />❑ This UST facility is NOT APPROVED to operate <br />1101�0 Z.r��d _ L l�' <br />fip mace <br />pi 1 v ,e t t v, 14 f;, <br />to 1,,2,-0 C:G L,� 0-4 e0 <br />, d�= <br />No "L <br />1 11E <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />�^^ <br />EHD Ins pe r: 2ma <br />Received By: �- <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />