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oPa�IM• c <br />SAN JOAQUIN COUNTY <br />Z -r�r• ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />• •P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.smciov.org/ehd <br />hi pR�` <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Faci ' Name: <br />Inspection Date: <br />Facility Address: <br />� .PA q,!�W <br />Service Request #: + <br />O site Service Technician's Name: <br />ICC Servicefecithiciantinstaller Exp. Date: <br />Manufacturer` Training: y' <br />SERVICE <br />14w <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 />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />04 <br />❑ <br />❑ NA <br />P <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: _ <br />❑ NA <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) <br />l� This UST facility is APPROVED to operate <br />SERVICE <br />14w <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 />k <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 aro required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel <br />04 <br />❑ <br />Corrosion protection <br />P <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />14w <br />WN <br />�/��I►1 � �� � r � n t►t %Ian 1�:'I� �. ti �L � ` r <br />1► 1,�All /q 11 �� / �� / / <br />:.MSW '� <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY <br />�ori i+ <br />'W <br />Ead�' <br />k <br />. J <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />