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OPgU l!y C <br />?� ��''•�� SAN JOAQUIN COUNTY <br />Qr ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />. P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />qui F ii R�� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />d e- /4/- <br />,vDV 1�!- r 3 13 <br />Facility Address: <br />Service Requ st #: <br />1403 Cat,n::- c1,& <br />5P-006 � Lf 41, 6 <br />Onsite Service Technician's N me: ICC Service Techniciantinsta�Exp. Date: <br />Manufacturer Training: <br />Leak detector <br />❑ <br />SERVICE <br />bela, <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />1z/R�e/( /�J'ved//B�/`y'J/-Jl/ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <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 overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />bela, <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 />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />1z/R�e/( /�J'ved//B�/`y'J/-Jl/ <br />minutes <br />-tie: 71 <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 />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />c 1,01,CtA <br />bela, <br />'{ r <br />d f <br />U G• 1 c <br />THIS FACILITY IS SUBJECT TO REINSPECTI N AT ANY TIME A <br />END'S CUR ENT HOURLY RATE. <br />EHD In " <br />1z/R�e/( /�J'ved//B�/`y'J/-Jl/ <br />-tie: 71 <br />EHD 23-04 v / <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />