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ARt <br />?-•'--�+�'••� SAN JOAQUIN COUNTY <br />-� ENVIRONMENTAL HEALTH DEPARTMENT <br />h: `{ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />(9as A4ta <br />n <br />Inspeq-Q�q <br />Facility Address:: <br />i <br />Vmdo V� <br />Service Request #. <br />JerG0a2 /U j. <br />Onsite Service Technician's Name:ICC <br />Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />'� <br />Leak detector <br />I r� /I (e <br />❑ mechanical Model: <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 />❑ 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 />❑ <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 />AThis UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket Xminimum 5 gallon <br />%1 hour hydrostatic 01 ncon TS -STS <br />❑ Caldwell System 'XOther 'B1-tt��- cJv <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 21 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 />.4111 15161@' <br />RTZ"Xim/ orl4miLwImlo-!, VIA FA <br />r. <br />EHD 23-04 C UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />