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Pq,U I ly ! i <br />SAN JOAQUIN COUNTY <br />cr -+ ENVIRONMENTAL HEALTH DEPARTMENT <br />.`. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si-iov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fat' ili y Name: <br />III 11AII I � & 4 <br />Inspe ion <br />ate: <br />Faci ty Address: <br />Vo V ' 01 <br />Service Request #: . . <br />V14 <br />ite Service Technic /' Name: <br />:;M <br />ICC Service Technician/Installer Exp. Date: <br />6i <br />Manufacturer Training: <br />%1 , W r� <br />� 14 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACI ITY IS SUBJECT/TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 />❑ <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 />LA <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 />THIS FACI ITY IS SUBJECT/TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 />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 />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 UST SERVICE REQUEST INSPECTION REPORT <br />Re14/3 0/1 <br />ej a&ii A41Lt` <br />THIS FACI ITY IS SUBJECT/TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD I ector: <br />i6 <br />eceived By: <br />< �( ilec <br />Titl _--- <br />11 <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Re14/3 0/1 <br />