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k- <br />�'' p SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />_0 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www .sigov.or /g ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />® - <br />Fac11 ility Address: <br />L' <br />Service Request #: <br />,1 <br />Onsite Service Technician's Name: q <br />l <br />ICC Service hnician installer Exp. Date: <br />Manufacturer Training: <br />SERVICE <br />Leak detector <br />mechanical Model: V t- <br />❑ <br />❑ electronic Serial #: jr5riL41 2q�m <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />EO�-- <br />Drop tube with mechanical overfill at 95% <br />erfill prevention (see LG letter 150-1) <br />SERVICE <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 />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />LIDC(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 />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />i1►'WWOU0,.► <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />