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OP••�u I N••.0 \/ <br />SAN JOAQUIN COUNTY <br />Q. ENVIRONMENTAL HEALTH DEPARTMENT <br />N'. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />'�• .P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />gGiFpaN� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name:Inspictii <br />TID <br />n� t� <br />C / <br />1 <br />Facility Address: <br />2 gL�� <br />Service Request #: <br />skoo� I� <br />Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: <br />M to �2 "1 -1-/r6 <br />Manufacturer Training: <br />Nov <br />k,-�t ,5"17-0 <br />SERVICE <br />I190% � eS-1 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />►� ` (Q. 5 d i C <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />TION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <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 />❑ This UST facility is APPROVED to operate <br />SERVICE <br />I190% � eS-1 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />►� ` (Q. 5 d i C <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 />TION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />minutes <br />Secondary containment testifor: d;� <br />UDC(s) c0it Piping <br />Sump(s) UST(s) <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 />O trJ eco -2, rd-- <br />I190% � eS-1 <br />v,.; Z o -s o <br />on / a <br />kh :v 'h s We <br />►� ` (Q. 5 d i C <br />�l �a►n s �--�� P P <br />o <br />see I�r� <br />TH CILITY IS SUBJECT TO REINSPE <br />TION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD I ector:Receiv <br />e- {.' <br />EHD 23-04 <br />Rev 4/30/12 <br />J UST SERVICE REQUEST INSPECTION REPORT <br />