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oPa�IN• c <br />SAN JOAQUIN COUNTY <br />�r y ENVIRONMENTAL HEALTH DEPARTMENT <br />e. a <br />W <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Y. <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*- ov.org/ehd <br />i.6 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: r <br />Inspection Date: <br />126 <br />Facility Address: <br />do e) , � �c�c <br />Service Request #: <br />S —cr <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />v B5Y2,Y-�- <br />❑ line test programmed <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 />sensor <br />❑ <br />❑ positive shutdown Model: <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 />11 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 />minutes <br />C LITY IS rkUBJECT TO REINSPECTI N AT AM TIME AT EHD'S CURRENT HOURLY RATE. <br />Secondary containment testing for: <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 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 />�/ v - <br />EHD 23-04 j/ <br />J/iv \ `✓/ <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />C <br />- <br />T IS F <br />C LITY IS rkUBJECT TO REINSPECTI N AT AM TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins p c r: <br />Rec ' By: <br />Title: <br />�/ v - <br />EHD 23-04 j/ <br />J/iv \ `✓/ <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />