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Ir 'y .cQGA 2T�•!' 'Y CQ�xF?O��P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web www.sigov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: ( • L/kC Inspection Da q f /a Facility Address: t/L plkk�� 4K Service Rguest #:gj%) i 21 ii Service echnicia arae: ]cc S rvi Technicia Installer Exp. Date: M n facturer Trainin : SERVICE • L/kC Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: jTrp)jt ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ 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 • L/kC 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 jTrp)jt Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sumps) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 2' containment components are required to be tested upon installation, 6 months atter, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection Other: see below ❑ This UST facility is NOT APPROVED to operate ! • L/kC THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. jTrp)jt eived By: Id h'� Title:t 123-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12