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OP�ufN C . <br />?•'—•F�''9 SAN JOAOUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT - <br />�: 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />. a.. P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siclov.orq/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />1Z- <br />De-,- z <br />Facility Address: <br />Service Reques #: <br />ICt,b 2 <br />s,��f�sca <br />Onsite Service Technician's N e: <br />ICC rvice echnicianAnstaller Exp. Date: <br />Manufacturer Training: <br />i �r <br />01':4- j fes' <br />1^ur�� 'f <br />SERVICE <br />(1 n <br />t <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />IEHD Insp o <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 />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />❑ This UST facility is APPROVED to operate <br />SERVICE <br />(1 n <br />t <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />IEHD Insp o <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 />Secon ary containment testing for:rk��,c <br />I UDC(s)g%i Pirnrg <br />Sump(s) UST(s) <br />Testing for the above components are next due by: <br />A <br />Note: Please be aw re 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 />��k� .– r • C �-IJ22r-- %A c% l <br />(1 n <br />t <br />rh,� lrolind 4— ns; , <br />THI CILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />IEHD Insp o <br />Received By: f <br />Title: <br />EHD 23 - <br />Rev 413 <br />UST SERVICE REQUEST INSPECTION REPORT <br />