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Aqu t ry 46 <br />SAN JOAOUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />'. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />'q ;P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />��FORN <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />1 <br />❑ <br />Facility Address: <br />Service Request #: <br />RX E y0�ev►- (-4Ave0, OutC OcL <br />-1AZ (O q3 <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ <br />--� p — �.J I b <br />VL — — <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />01 Q-6 <br />❑ electronic Serial #: <br />` <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 />EHD inspector:�,A <br />❑ fail safe Serial #: <br />Title: <br />❑ NA <br />❑ <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />01 Q-6 <br />❑ Caldwell System ❑ Other <br />` <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 />EHD inspector:�,A <br />UDC(s) Piping <br />Title: <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 />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <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 />5(2 tA <br />01 Q-6 <br />X) lill u2U <br />` <br />O <br />L C,0 to CL <br />r, <br />THIS FACILITY IS SUBJECT TO REINSPECTION_ AT AN .TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD inspector:�,A <br />In N Received <br />j/)) OLA&,-- <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />