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PqU 1!y <br />SAN JOAQUIN COUNTY <br />y { <br />*ENVIRONMENTAL HEALTH DEPARTME <br />` . 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />q�1FOR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facili Name: <br />Inspection Date: <br />Leak detector <br />❑ <br />Facility Address: j <br />Service Request #: <br />Onsite Service Technician's Name: <br />"' <br />U %f k� <br />ICC Service Tech noci n/Installer Exp. Date: <br />� 7 -a -G <br />Manufacturer Training: <br />Ivrz, I <br />(,L <br />Leak detector <br />❑ <br />r rI <br />ERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIWhClLlg IS SUB CT TO REINSPECTIO AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />El <br />U ensor <br />1),;q0_ positive shutdown Model: j ,, `SCO-YZd <br />❑ fail safe Serial #: S27 , 7 <br />❑ NA <br />��+vd>ti ensor dL <br />Model: -I `1 Oo <br />El <br />positive shutdown <br />El 7 <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 />CI This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIWhClLlg IS SUB CT TO REINSPECTIO AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 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 />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />�IAAAfev <br />THIWhClLlg IS SUB CT TO REINSPECTIO AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspect <br />\ <br />Recei,'2z <br />Title: <br />EHD 23-04 / v UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />