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OPgV l�!. C <br />SAN JOAQUIN COUNTY <br />y; ?< ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />�4�iFOR��P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />z / / z0 i 1-t <br />Facility Address: <br />o �►��--- �I B S ckf�� <br />Service Request #: <br />5A va (r 1`7 C 5S <br />Onsite Service Technician's Name: <br />ICC Service Technician/installer Exp. ate: <br />�1 L�4r_ /I mlq <br />Manuf cturer Training: <br />wl g/lS- <br />THIS FACILITY IS SUBJECT TO REINSPECTIOWAT ANY TI AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />SERVICE <br />f 50(4- Iona <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTIOWAT ANY TI AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ lin teat programmed <br />•sensor ¢ <br />-Mode: <br />ositive shutdown <br />it safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ positive shutdown Model: <br />❑ <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 />XThis UST facility is APPROVED to operate <br />SERVICE <br />f 50(4- Iona <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECTIOWAT ANY TI 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 />❑ <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 />/=Z� �� �� �u 1 <br />f 50(4- Iona <br />S( n <br />THIS FACILITY IS SUBJECT TO REINSPECTIOWAT ANY TI AT EHD'S CURRENT HOURLY RATE. <br />EHD In cto : <br />Received., <br />Title: <br />EHD 23- <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />