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Op4UIN• C SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT im 1868 East Hazelton Avenue, Stockton, CA 95205-6232 • c P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd 4�/�pRN UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: Leak detector ❑ Facility Address: Service Request #: tovs-g SR 00bo.),- Onsite Service Technician's Nam : ICC Ser a Te hnician/Installer Exp. Date: Manufacturer Training: 14& 'an ❑ mechanical Model: SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: . ❑ line test programmed Inctor- 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 95010 Drop tube with mechanical overfill at 95% Overfill prevention (see LIS letter 150-1) 6j 9Oe Y yo,tThis KST facility is APPROVED to operate SERVICE 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 L Primary piping testing at: �, vie,'�Q g . psi a/ S -7 d5L Inctor- 1 minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 2° 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 3,(8 ❑ This UST facility is NOT APPROVED to operate 110 r+5 w,d EHD 23-04UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12 1 O1 fill Mim WPM I _. Ar W . . - .'r -�EHD Inctor- EHD 23-04UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12 1 O1