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• ogQ uv if c ?• ' •o SAN JOAQUIN COUNTY ip -+ ENVIRONMENTAL HEALTH DEPARTMENT y 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT FaciliName: / r Inspection Date: Leak detector l -r-, -70-I Facility Address: C Hn Service Request #: QV j Onsite Technician's Name: ICC Service T hnician/Installer E p. Date: Manufacturer Training: /S�e'rvice te1V Mev' ❑ mechanical Model: e -E IRM111 ire SERVICE 4�I�r� i . �i �.I REti � r Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: j ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: e -E IRM111 ire ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) ❑ This UST facility is APPROVED to operate SERVICE 4�I�r� i . �i �.I REti � r Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other j Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other e -E IRM111 ire Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping _ Sump(s) UST(s) Te irlg5for the above components are next due by: Note: Please be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate 1 r . • �� 4�I�r� i . �i �.I REti � r WA.. ._ .. W■i:u _ �'� <<�l /► .•. a. WOR 04 j e -E IRM111 ire Fj EHD 23-04 Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT