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o�Q� I.N• c <br />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.sugov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Gr L-i.(:�- x-70 <br />1-4— 7--) -z' <br />Facility Address: <br />Service Request M <br />❑ line test programmed <br />-7 64(i 2---3- <br />-3Onsite <br />OnsiteService Tech tcian's Name: <br />ICC Service Technician/installer Exp. Date: <br />Manufacturer Training: <br />❑ electronic Serial #: <br />SERVICE <br />Kylechanical <br />Leak detector <br />Model: ���-J�2�•r� <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <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 LIS 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 />THIS FACILITY 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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />"El <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 !� W v <br />UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: or <br />R cei edy <br />Title: <br />EHD 23-04 !� W v <br />UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />