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0?'0.� IN••.c <br />SAN .JOAQUIN COUNTY <br />Q - ENVIRONMENTAL HEALTH DEPARTMEi <br />1. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />C'gCl oRa�P <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sugov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Vii e c IT-zxn p %� �3 // 0 / f 4 - <br />Facility A ss: Service Request #: <br />152q SP- 0 C) (0q 12--9 <br />rrr Ss.^„es i Bet Manufacturer Training: <br />P <br />lleer i Z-1b13re/l- I Adva-*? d �eo�um <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />t <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />It <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />t <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />It <br />IOther: see below S'1/n�a1/YJ - <br />El UST facility is APPROVED to operate, This UST facili is NOT APPROVED to operate <br />n el/, IX/1 �' "74 --h1 /.l i,-,7,- n 1%rty �/a �� n /r /snit A," <br />% fJl <br />. 910P <br />HIM, <br />=U01, <br />:1 lip a <br />WILY <br />t <br />• •Iiijill• <br />FAAll <br />Eli 23-04 \ J UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />