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Rquty • <br />SAN JOAQUIN COUNTY <br />a� 'a ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicov.oro/ehd <br />�tFORN <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: I <br />Ins? Dat06?)e* <br />El❑ <br />mechanical Model: <br />Facility dress: <br />�,(j_ <br />`-� <br />Service Request#: <br />to Service T hn130n�'s(N/a' me. <br />ICC Servicb TechniciViridirt,11 <br />rr�E P Date: <br />Manufafturer raining: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />SERVICE <br />_ Leak detector <br />El❑ <br />mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />E]❑ <br />mechanical Model: <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 />El❑ <br />positive shutdown Model: <br />❑ fall safe Serial #: <br />❑ NA <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 />This UST facility is APPROVED to operate <br />5 <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 />I Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />1 t THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD 23-04 / \ /� /v ��% UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 �/ v <br />