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opa`uvl'" c SAN JOAQUIN COUNTY Q` �a ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax; (209) 468-3433 Web: www.sigov.org/ehd C9i%FOR�`P UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: Leak detector ❑ Facility Address: Service Request #: / 46,q L ��.F ., �!L ofl 6z c>--> L - Onsite Service Technician's Name: ICC Servic®ian/Installer Exp. Date: Manufacturer Training: / 4+ ❑ -X — 4ecr- X - ► i 6 SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed �Jor covr�v�� sensor ❑ ❑ positive shutdown Model: }/�'. j�dCt� [i •, ' (G1 . ❑ fail safe Serial #: LY RATE. ❑ NA I 7eiv�� sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) ❑ This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi �Jor covr�v�� minutes -/ B�i' �l N G 511` I 'IAV► I,.� •.s Secondary containment testing for: }/�'. j�dCt� [i •, ' (G1 . ro UDC(s) Piping LY RATE. Sump(s) UST(s) I 7eiv�� Testtii�njg for the above components are next due by: I Title: Note: Plelse be that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate EHD 23-04 Rev 10/06/1 UST SERVICE REQUEST INSPECTION REPORT f� 1 i O.41L a.AC.3 /L'r-v -4 ►1 �Jor covr�v�� -/ B�i' �l N G 511` I 'IAV► I,.� •.s rl W�^ K l o -5e C lr �l 1, G` }/�'. j�dCt� [i •, ' (G1 . THIS FACILITY IS SUBJECT fO REINSPECTION AT AO TIME AT EHD'S CURRENT HOU LY RATE. EHD In r: I 7eiv�� I Title: EHD 23-04 Rev 10/06/1 UST SERVICE REQUEST INSPECTION REPORT