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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 46&3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />P&h <br />/ / vz�v <br />InspectionDate: <br />.IQSE Spill bucket ❑ minimum <br />Leak detector <br />Facility Address: <br />, <br />Service Request <br />ry <br />mechanical <br />Model: <br />Onsite Service Technician's Name: <br />electronic <br />ICC Service Technician/installer Exp. Date: <br />Manufacturer Training: <br />lit) <br />❑ This UST facility is APPROVED to operate <br />This UST facilit is N01 <br />SERVICE <br />SERVICE <br />.IQSE Spill bucket ❑ minimum <br />Leak detector <br />❑ <br />❑ <br />mechanical <br />Model: <br />❑ <br />electronic <br />Serial #: <br />❑ 1 hour hydrostatic ❑ Incon T&STS <br />❑ line test programmed <br />❑ Caldwell System ❑ Other <br />Leak detector <br />Primary piping testing at: <br />❑ <br />❑ <br />mechanical <br />Model: <br />❑ <br />electronic <br />Serial #: <br />Secondary containment testing for: <br />❑ line test programmed <br />UDC(s) <br />Piping <br />sensor <br />Sump(s) <br />❑ <br />❑ <br />positive shutdown <br />Model: <br />❑ <br />fail safe <br />Serial #: <br />❑ <br />NA <br />Corrosion protection 9/ <br />sensor <br />❑ <br />❑ <br />❑ <br />positive shutdown <br />Model: <br />❑ <br />fail safe <br />Serial #: <br />❑ <br />NA <br />sensor <br />❑ <br />❑ <br />positive shutdown <br />Model: <br />❑ <br />fail safe <br />Serial #: <br />❑ <br />NA <br />❑ <br />Drop tube with <br />mechanical overfill at 95% <br />❑ <br />Drop tube with <br />mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />This UST facilit is N01 <br />SERVICE <br />.IQSE Spill bucket ❑ minimum <br />5 gallon <br />❑ 1 hour hydrostatic ❑ Incon T&STS <br />EHD Inspecto <br />Received By: 1 <br />❑ Caldwell System (OtherevrW-6/7 <br />Spill bucket ❑ minimum <br />5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon T&STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) <br />Piping <br />Sump(s) <br />UST(s) <br />Testing for the above components are <br />next due by: <br />Note: Please be aware that 20 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 />Corrosion protection 9/ <br />❑ <br />Other: see below <br />EHD 23-04 <br />Rev 4/30/12 <br />-'� UST SERVICE REQUEST INSPECTION REPORT <br />t <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspecto <br />Received By: 1 <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />-'� UST SERVICE REQUEST INSPECTION REPORT <br />