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`A <br />SAN .10AQUlN COUNTY <br />e ' A tNVIRONMENTAL HEALTH DEPARTMENT <br />di 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 />Leak detector <br />UI 14 <br />Facility Address: <br />il0 <br />Service quest <br />,-2 +4 0 Vci ri I e d s St +e« il <br />a <br />Onsite Service Technician's Name: <br />ICC Servide Technician/Installer ll Date: <br />Manufacturer Training: <br />Warod Bur <br />V14114 /G <br />Vc lr Rl _9 19 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Y1 > <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑1 <br />❑ line test programmed <br />I qq <br />380 3z3 sensor <br />K positive shutdown Model: 3 23 VeeJLt ko0 <br />❑ fail safe Serial #: q75G 2 <br />0 N Farm. '743Y 3 g 2 <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 />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />1 This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Y1 > <br />Ll Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑1 <br />psi <br />eceive y: <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sumps) 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 />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30112 <br />Y1 > <br />THIS FACILITY IS SUBJECT TO Rp4pPECTIO <br />T ANY TIME AT END'S CURRENT HOURLY RATE. <br />El Inspector;f1 <br />t C k-1 ! � �/� � (' Ca r +n il <br />eceive y: <br />Title: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30112 <br />