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°Pa"tN 'O SAN JOAQUIN COUNTY <br />6NVIRONMENTAL HEALTH DEPARTMENO <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />A�fFOR�` <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />amg&� L-XI"9 ;rlx)q�f_ -r-C42-to— <br />rI/ t, X0/3 <br />Facility Address: <br />Service Request #: <br />S& <br />Onsite Service Technician's e: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />G44 ez <br />0'/ --2 3 -01013 <br />05 2d -1 <br />SERVICE <br />R Leak detector <br />❑ <br />�K 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 />Received By, <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 />❑ <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 />Received By, <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 />Rev4 <br />Rev 4 <br />UST SERVICE REQUEST INSPECTION REPORT <br />'�S � J e C.�i'.c•C.cI <br />�7 `.'ctiC Z/ �f C'<"!t /1 r' !'�.� � '7L�.� L . <br />134111S.FCIL!Y IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EH nspe or <br />Received By, <br />Title: <br />Rev4 <br />Rev 4 <br />UST SERVICE REQUEST INSPECTION REPORT <br />