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�Pqu t N <br />SAN .JOAQUIN COUNTY <br />Q: ENVIRONMENTAL HEALTH DEPARTMENT <br />N. f 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Q� <br />lrO - l <br />electronic Serial #: <br />rill I <br />s <br />Facility Address: <br />Service Request #: <br />M 16 6A <br />/ <br />V�IV&O <br />- ,mil 1 �� L.. <br />Onsite Service Technician's e: <br />❑ <br />IC&Sbrvice Technician/Installer Exp. Date: <br />Manufacturer Training: <br />% r\ & M rn <br />❑ <br />❑ positive shutdown Model: <br />M- . t -O s <br />LIN] <br />SERVICE <br />%t Leak detector <br />mechanical Model: <br />Your <br />electronic Serial #: <br />rill I <br />s <br />line test programmed <br />Leak detector <br />V <br />❑ mechanical Model: <br />- ,mil 1 �� L.. <br />Xelectronic Serial #: <br />❑ <br />❑ line test programmed <br />- s ' I ti • • <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />EHD .: I`' <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />Drop tube with mechanical overfill at 95°'0 <br />!E1 <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 />Your <br />VIhydrostatic ❑ Incon TS -STS <br />rill I <br />s <br />❑ Caldwell System I)4Otherdw T <br />Spill bucket minimum 5 gallon <br />1 hour hydrostatic ❑ Incon TS -STS <br />V <br />❑ Caldwell System XOther t-, W - <br />- ,mil 1 �� L.. <br />Primary piping testing at: <br />❑ <br />psi <br />- s ' I ti • • <br />minutes <br />Secondary containment testing for: <br />EHD .: I`' <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />XThis UST facility is NOT APPROVED to operate <br />El 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />rill I <br />s <br />_ <br />- ,mil 1 �� L.. <br />1. • • ,� <br />1� �! <br />® <br />Lim. 111 <br />- s ' I ti • • <br />EHD .: I`' <br />A A <br />El 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />