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Op'QUlfy C � • SAN JOAQUIN COUNTY cr a ENVIRONMENTAL HEALTH DEPARTMENT H: ?, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 C{•., _ �P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.segov.org/ehd 4�hi UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facilit Name: Inspection Date: () �" - y L+ I - - I H Faci y Address: Service Request #: 7a --7,� W est an c_ -h,r\ i I6 7aq Onsite Service Technician's Name: ICC Service TechnicianAnstaller Exp. Date: facturer Training: h -� 01 u ��5 -I (o rvau , a I - .I 4 - -,do SERVICE i� Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ 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 i� Spill bucket ❑ minimum 5 gallon ❑ 111 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for 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 cA' LC -4 � c.�►< i� THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspector: �) Rece' By:�CllTitle: ( EHD 23-04 / v UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12 !!