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pqulN <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />,.P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sidov.orci/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Leak detector <br />Z ' Lz - <br />Facilit dress:N <br />S� Q <br />Service Request #: <br />�) in 6, IVA <br />(T Ar <br />❑ line test programmed <br />❑ <br />Onsite Service Technician's Nam <br />ICC Service Tech ician/Ins aller Exp. ate: <br />Manufacturer raining: <br />❑ electronic Serial #: <br />❑ <br />SERVICE <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 />EHD Inspe .� <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 />❑ <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 />'`t'- 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 />EHD Inspe .� <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 20 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 />'. <br />l <br />4\4 L c 414 <br />! , ,r A <br />I .r <br />°- C'JAI T <br />6n 4 4 <br />t <br />THIS FACILITY IS SUBJECT TO REINSPECTIO N <br />TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspe .� <br />Re c eived By: <br />Tit S' ev uKr— 14-th - <br />EHD 23-04 <br />� U <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />