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�qu r ly <br />x• ..r, .o <br />;.:_...�;,�„•, .� SAN JOAQUIN COUNTY <br />s ENVIRONMENTAL HEALTH DEPARTMENT <br />`W <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orp/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />ev no <br />0 3 <br />/171 1& <br />Facility Address:y <br />19 6 0W. 11Y —1 <br />S-h-ee+ Tne4e,64 <br />Service Reque #: <br />SR po'7 /(, z <br />Onsite Service Technician's Name: <br />ICC Service Technician/installer Exp. Date: <br />Manufacturer Training: <br />Sa rn 1. r -*Bellew YXrU <br />H D <br />❑ electronic Serial #: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />L I <br />❑ electronic Serial #: <br />r <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 />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />EHD Inspe <br />F <br />❑ NA <br />iCorrosion <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 />L I <br />❑ Caldwell System ❑ Other <br />r <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />e <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 />EHD Inspe <br />F <br />protection <br />iCorrosion <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />w /Tt <br />r <br />3 ° s sem <br />L I <br />r <br />ail 6 rX+ <br />e <br />G, <br />sdazlol�f <br />-4 <br />-^/ <br />, ✓ 4 41P elf <br />12 dA L�42,4�y <br />THIS aCILITY IS SUBJECT TO REINSPECTION AT <br />ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspe <br />F <br />Re <br />Title: <br />I/--- <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />