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utN SAN JOAQUIN COUNTY Q , ' ENVIRONMENTAL HEALTH DEPARTMEN. N. 1864 East Hazelton Avenue, Stockton, CA 95205-6232 CqC� Telephone: (209) 468 j5,-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: 60 kv,. a IrdO l l� Facility Ad r s: Service Request #: L524 �� Op(� Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Tranp: ❑ /0/-7//,57 T1 3)3 1 v SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: XTesting ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) ❑ This UST 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 Primary piping testing at: �SCpsi p0 minutes Scondary containment testing for: IV UDC(s) A-11 Piping Sump(X UST(s) XTesting for due the above components are next s ,ham- 2 0 > C�� Note: Please be aware that 20 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 X This UST facility is NOT APPROVED to operate � v EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12 • r- MA , M FORW Yom;NA i POR I 0711-Aff !� W -- ! •% tf � v EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12