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RQUI(y <br />�o.• _ . -. ..co SAN JOAQUIN COUNTY It <br />y ENVIRONMENTAL HEALTH DEPARTMENT <br />W. x <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.ora/ehd <br />��1FOR� <br />UNDERGROUND STORAGEREQUEST REPO <br />Facility Name: <br />t <br />Inspection Date: <br />I � <br />Facility Address: jService <br />ejot <br />Request #: <br />�— <br />Onsite Service Technician's Nay <br />q <br />ICC Service Technician/Installer Exp. Date: <br />01 <br />ufacturer Training: <br />Z,-121 <br />" ` <br />VT ! ZD <br />�) <br />SERVICE <br />LM <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />Leak detector <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ mechanical <br />Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic <br />Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />. y ' WrIn <br />❑ <br />❑ mechanical <br />Model <br />❑ electronic <br />Serial #: <br />Secondary containment testing <br />UDC(s) oPfor � Piping <br />❑ line test programmed <br />Sump(s) UST(s) <br />sensor <br />Testing for the above components are next due by: <br />❑ <br />❑ positive shutdown <br />Model: <br />Cold start of monitoring panel <br />❑ fail safe <br />Serial #: <br />❑ <br />❑ NA <br />sensor <br />El <br />❑ positive shutdown <br />Model: <br />❑ fail safe <br />Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown <br />Model: <br />❑ fail safe <br />Serial #: <br />❑ NA <br />❑ <br />Drop tube with <br />mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />LM <br />❑ 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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />. y ' WrIn <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing <br />UDC(s) oPfor � Piping <br />Sump(s) UST(s) <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 />19 This UST facility is NOT APPROVED to operate <br />I WE <br />. y ' WrIn <br />, iz ra �i r�► <br />le i . �� itis <br />11TH j :� • / j <br />ZX'Ziol'i <br />01 <br />EHD 23-0#// !f v �/ UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 S/ <br />