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pqulN <br />a�'i •••p <br />2-• ��,� , .c SAN JOAQUIN COUNTY <br />2 ENVIRONMENTAL HEALTH DEPARTMENT <br />Q: a <br />•• <br />V. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />__ __' .P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicov.or0/ehd <br />d<F <br />i O'RN� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Leak detector <br />❑ <br />Facility Address: <br />Service Request #: <br />as oj <br />S 01o8a <br />Onsite Service Technician's Name: V <br />IC Service Technicia Ins alter Exp. Date: <br />Training: <br />u LQ <br />- <br />1Mann((u''f��acturer <br />V tt -- Ilto— — <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 />❑ electronic Serial #: <br />❑ <br />❑ line test programmed, <br />sensor 51 P— <br />positive shutdown Model: Log <br />fail safe Serial #: I D <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fall 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 />his UST facility is APPROVED to operate <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 />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 />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />0 WWI <br />WE noJWltp&iwmmz <br />I HE nal <br />I <br />�•f r O �. I• • .• �!' Vii._.' <br />THIS FACILITY IS SUBJECT TO REINSPECTIOYAT ANYtTpAq•HOURLY <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />