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OPgUIN• C ?' 11116 ' O SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd Cq� iF iiRa`P UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT F tt N me: IV4,11d z Inspection Date: ❑ ❑ mechanical Model: �7—q A Facility Address: �, Service Request #: Onsite Service Technician's Name: ICC Service Technician/ taller Exp. Date: Manufacturer Training: ❑ mechanical Model: ❑ electronic Serial #: SERVICE z Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed M sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA 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 z 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 M minutes Title: S cWdary containment testing for: 1 UDC(s) Piping 91 4 2-V'! ump(s) UST(s) T sting fort a above components are next due by: Note: PI se be aware that 20 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 4/30/12 i UST SERVICE REQUEST INSPECTION REPORT z TH FACILITY IS UBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspe M Recei ed y: r Title: EHD 23-04 Rev 4/30/12 i UST SERVICE REQUEST INSPECTION REPORT