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o.°iaRIN••.0 <br />SAN JOAQUIN COUNTY <br />e'ENVIRONMENTAL HEALTH DEPARTMENT <br />,.', 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.org/ehd <br />9�fFORN` <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility e: <br />Na7a <br />1�,vo <br />Leak detector Q Cf L ZE <br />�' <br />19 <br />I1'mechanical Model: <br />Inspection Date• <br />%o <br />Facility Address: <br />" i ►' <br />❑ line test programmed <br />❑ <br />Service Request M <br />Onsite Service Technician's Na e: <br />r d ; <br />ICC Service Technician/Installer Exp. Date: <br />SO 1 4i AW <br />Manufacturer Training: <br />V9 610%49-5Z 00/2013 <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Recei y: <br />r <br />i Y W-2-1 , -, ^. s <br />SERVICE <br />L 6 ✓1 -ea <br />Leak detector Q Cf L ZE <br />�' <br />19 <br />I1'mechanical Model: <br />V o -H ur r <br />❑ electronic Serial #:I Ob Cf <br />" i ►' <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Recei y: <br />r <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <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 />Overfill prevention (see LG letter 150-1) ktoij <br />This UST facility is APPROVED to operate <br />SERVICE <br />L 6 ✓1 -ea <br />T Spill bucket ❑ minimum 5 gallon <br />19 <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />V o -H ur r <br />❑ Caldwell System ❑ Other <br />" i ►' <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />kP-4-s6tA, <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />Recei y: <br />r <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 />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 />❑ This UST facility is NOT APPROVED to operate <br />,. ® S,ef\Y-- kR- \kJ i e -S <br />L 6 ✓1 -ea <br />Fa S 5ci l <br />Ne <br />4 o <br />V o -H ur r <br />VJ r, C <br />" i ►' <br />�J D oL5 - <br />/' 7 L <br />-1 bur <br />kP-4-s6tA, <br />G I , <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspe r: <br />Recei y: <br />r <br />Title: , <br />P <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />