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°t'gutN ° SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*gov.org/ehd <br />1FOR�` <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />G -� '4k �- <br />Facility Address: at-4, <br />� / Service Request #: <br />C1 c�..� at- i7 [l 0S [� /� CD <br />Onsite Service Technician's Name: ICC Service T hnician/Installer Exp. Date: Manufacturer Training: <br />t'-� V)ez1 <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 />Zoc <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />1095—r— sensor (z <br />❑ positive shutdown Model: Pa. --c.. _ 3 <br />THIS FACILITY IS SUBJECT TO'RIEIIQSPECTION <br />❑ fail safe Serial #: <br />T EHD'S CURRENT HOURLY RATE. <br />0 N "5+.ZL"J <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 ovefll at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />CJ tJ 114 <br />❑ Caldwell System ❑ Other <br />Zoc <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />THIS FACILITY IS SUBJECT TO'RIEIIQSPECTION <br />UDC(s) Piping <br />T EHD'S CURRENT HOURLY RATE. <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Title: <br />��� LI ��rlor✓ <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 />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 L/A v UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />1 <br />r <br />a q9121 <br />yjr_ /4 <br />CJ tJ 114 <br />GE' <br />Zoc <br />qq <br />i � <br />(C3L— <br />THIS FACILITY IS SUBJECT TO'RIEIIQSPECTION <br />AT ANY TI <br />T EHD'S CURRENT HOURLY RATE. <br />EHD Insp <br />� <br />Received By: <br />Title: <br />��� LI ��rlor✓ <br />EHD 23-04 L/A v UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />