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/RAa` .c� <br />SAN .IOAOUIN COUNTY <br />Q ENVIRONMENTAL HEALTH DEPARTMENT <br />N.1W 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />�,;c•P:` Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />-.�tFbRN. <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fa ility Name: <br />Inspection DatApt%e:�(� I(� <br />Leak detector <br />��' 0AU 6D <br />Facility d ress: V <br />Service Request #: <br />k � tri e (� <br />5 ID3 <br />Onsite Service Technician's Name:[cc <br />Service Technician/installer Exp. Date: <br />Manufacturer Training: <br />W , <br />l <br />W0V-- "_q-1 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />R I LW971 <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 <br />❑ <br />❑ positive shutdown Model: <br />• • uCURRENT <br />❑ fail safe Serial #: <br />& <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 ❑ Incon TS -STS <br />R I LW971 <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 />• • uCURRENT <br />UDC(s) Piping <br />& <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 />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />A X <br />R I LW971 <br />• • uCURRENT <br />HOURLYRATE. <br />& <br />1 WIW07 <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />