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OAau tN•..0 <br />-'� '•° SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />h {i <br />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 />`�. <br />Inspection Date: <br />_No )li LR(k <br />❑ mechanical Model: <br />tis 12 2j(,- 15 <br />Facility Address: <br />Ei. .0 <br />%COM I l�Tt � tet/ <br />Servicb Req est #: <br />S <br />Onstt Service Tech ame: <br />Leak detector <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />Title: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />SERVICE <br />`�. <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />/ <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Title: <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 />❑ 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% <br />HO—Overfill <br />prevention (see LG letter 150-1) <br />�fl This UST facility is APPROVED to operate <br />SERVICE <br />`�. <br />Spill bucket .6minimum 5 gallon <br />USl <br />1 hour hydrostatic ❑ Incon TS -STS <br />/ <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />6 <br />❑ Caldwell System ❑ Other <br />Title: <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 21 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 />❑ This UST facility is NOT APPROVED to operate <br />©(SSI O iese <br />S G cwt 1%' t QiJ1I MmgVVt, <br />en i 'k:.. T <br />e z I <br />S 4 IIS, <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD Insp / i /� <br />jl l7'� Y1 <br />6 <br />Re d B <br />Title: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />