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O�qU I!v'•.0 <br />SAN JOAQUIN COUNTY <br />z�,��~ ? _NVIRONMENTAL HEALTH DEPARTMENT <br />y DIY, 1868 East Hazelton Avenue, Stockton, CA 95205-6.32 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si-ov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />SERVICE <br />j <br />Leak detector <br />mechanical Model: ✓tya gg02000 <br />El <br />ED]electronic Serial #: 1,20!3 % 02T <br />❑ line test programmed <br />THIS fAqILITY I SUB ECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />❑ <br />Overfill prevention (see LG letter 150-1) <br />This UST facility is APPROVED to operate <br />SERVICE <br />It <br />Spill bucket 11minimum 5 gallon <br />El <br />1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS fAqILITY I SUB ECT 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: <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 />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 />4c-ql-r-- X29 yi >rc3r�S r Ge-Le— <br />It <br />THIS fAqILITY I SUB ECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspe Receiv Y:� <br />Title: 7e -c 414 r Cl4. <br />VV <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />