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4� <br />SAN JOAQUIN COUNTY <br />Q' ENVIRONMENTAL HEALTH DEPARTMENT <br />N. .'. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.socov.org/ehd <br />'4.Ci r ORN"� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />`IJV <br />Inspection Date: <br />7 Ig <br />Facility Address: <br />Service Request #: <br />Onsite Service Technician's Name: <br />ICC Service Technician/Instiller Exp. Date: <br />Manufacturer Training: <br />,-540 V -n o r 0,n falo n <br />b -)-o (9 <br />w - I- - 19 ©� ' I <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />I <br />III <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />C151 I EN 5 sensor CLO RUI, T 5-0 r <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />— sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />_ sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />_Drop tube with mechanical overfill at 95910 <br />F-1 <br />Droptube with mechanical overfill at 95°'0 <br />❑ <br />Overfill prevention (see LG letter 150-1) <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 />I <br />III <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />t1 s 1 I1�1 <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 />Testing for the above components are next dueby: <br />q,:� O)PQ- & "Vuwi-t, • ksi <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 />Y,1 -1. -This UST facility is NOT APPROVED to operate <br />MW <br />----- <br />RevU4 30/12 `j� �� � ©f � UST SERVICE REQUEST INSPECTION REPORT <br />i. u� <br />1 • il/ <br />I <br />III <br />I r�,� �: 1_• _ .• <br />A � � er � <br />t1 s 1 I1�1 <br />- �� <br />♦ 0 01 310 1 M- <br />W -1,0011 <br />MW <br />----- <br />RevU4 30/12 `j� �� � ©f � UST SERVICE REQUEST INSPECTION REPORT <br />