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OP4uIN C0 <br />0� SAN JOAQUIN COUNTY to <br />Q' + ENVIRONMENTAL HEALTH DEPARTMENT <br />y. '. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />9�' F ORN <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />InspectionDate: <br />/A -Y -C-0 ---W <br />❑ mechanical Model: X12ii� <br />'A,electronic <br />-" 2/1 Z[)4 <br />Facility Address: <br />MOM <br />Service Request #: <br />: <br />Onsite Service Technician's Name: <br />ICC echnicia nstaller Exp. Date: <br />�ervic�e T <br />Manufacturer Training: <br />ti%gy S I�A�l`wa <br />12-6 iq <br />j 'c <br />V R X •) 2C Iia x. I�f�i iT <br />SERVICE <br />I&eak detector <br />❑ <br />❑ mechanical Model: X12ii� <br />'A,electronic <br />Serial #: <br />MOM <br />❑ line test programmed <br />❑ <br />cl I Leak detector <br />❑ Model: <br />mechanical <br />y ii/ <br />glectronic Serial #: <br />❑ <br />❑ line test programmed <br />tav _, sensor <br />,positive shutdown Model: `1%� <br />`ail <br />safe Serial #: <br />❑ NA <br />ensor <br />tpositive utdown Model: <br />❑ <br />ail safe Serial #: <br />❑ NA <br />• <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />XOther: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />tube with mechanical overfill at 95% <br />EDrop <br />Overfill prevention (see LG letter 150-1) <br />X 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 />MOM <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />y ii/ <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 />XOther: <br />see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 F UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 0�, red � r p1 ci W -t X.. t,<L, <br />�n 0—U— s Ck1Lry <br />11 <br />MOM <br />011111111t <br />JInii <br />�rL._ /. �� <br />y ii/ <br />1L �/ .Kfaxml- <br />OR <br />IPWE/ L /_-- ? L' <br />• <br />• <br />• <br />EHD 23-04 F UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 0�, red � r p1 ci W -t X.. t,<L, <br />�n 0—U— s Ck1Lry <br />