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o.�qu I N• .e <br />SAN JOAQUIN COUNTY <br />VIRONMENTAL HEALTH DEPARTMENT 101 <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax (209) 468-3433 Web: www.slgov.org/ehd <br />4�fi=out. <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name; Inspection Date: <br />Facility Address: Service Request #: <br />/-09?4 ._ 0,�5 6s6 I '7 <br />Onsite Service Technicians Na ICC Service Technic ia nil nstal ler Exp. Date: Manufacturer Training: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />F'Elmechanical <br />Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />Q <br />❑ positive shutdown Model.- <br />odel:❑ <br />71fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />LJ 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 />This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ In con 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 />y:Note: <br />Note:Please be aware that 2° containment components are required to be tested upon <br />inslallation, 6 months atter, and every 36 months thereafter. <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 />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD l ptor Rec Ive By: ^ Title: <br />EHD - 4 <br />Rev 41301 <br />UST SERVICE REQUEST INSPECTION REPORT <br />