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Op4u IN •.0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />�IppR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inction Date: sp <br />Leak detector <br />Facility Address: <br />LaAVo <br />Service Request #: <br />'Ek <br />C <br />CIO $3 <br />Onsite Service Technician's Name: <br />ICC Servic Tec nician/Installer Exp. Date: <br />Manufacturer Training: <br />VR Ll <br />rI ti, <br />1a -X4-1 <br />-'Io -q --I <br />SERVICE <br />4amon A. _ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />r <br />❑ electronic Serial #: <br />Ira PAM11:11111=10111 a 1191 1.1:11 0611:m" <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />y-t*positivb <br />to sensor <br />shutdown Model: <br />Mail safe Serial #: 1b�0 <br />❑ NA <br />i� <br />1 sensor <br />'apo itive shutdown Model: v —0.10 <br />❑ <br />Mail safe Serial* <br />❑ NA <br />sensor <br />((positive shutdown Model: V Q �� 8 <br />❑ <br />J$fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />4amon A. _ <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />r <br />❑ Caldwell System ❑ Other <br />Ira PAM11:11111=10111 a 1191 1.1:11 0611:m" <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 />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 />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br />r \ :* Dn o. :,.t a 11 n r.n4... n l n 1 _a n,, I,.,-4M✓u n , . A x --a 1- i , Ln. <br />► <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />4amon A. _ <br />I�� r i ' ► • t►� • I� <br />r <br />Ira PAM11:11111=10111 a 1191 1.1:11 0611:m" <br />Kam,1 ` W.N <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />