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.F ' •oma SAN JOAQUIN COUNTY <br />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.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection ate: <br />P 281/5 <br />Facility Address: <br />qd/ .DfbYQGI� :1� �'►c1�2 <br />Service Request #: <br />Sled �2�9�a <br />�S'� <br />Onsite Service Technician's Name: <br />ICC Se ice Technician/installer Exp. Date: <br />Manufacturer Training: <br />OP1.0 <br />❑ <br />Leak detector <br />❑ <br />SERVICE <br />a i �7, 15 R MA F� <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 />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />Drop tube with mechanical overfill at 95% <br />❑ <br />L❑ 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 />a i �7, 15 R MA F� <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 />170 1/1 101 rd <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Title: <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 />Corrosion protection C?1 S i110&7fV,lhta- <br />❑ <br />Other: see below <br />This UST facility is NOT APPROVED to operate <br />C-* q / crp/// 0 onlai&" ffX9C4 <br />EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 0 <br />a i �7, 15 R MA F� <br />170 1/1 101 rd <br />Received ByF��' 021- <br />I MA <br />Title: <br />EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 0 <br />