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SAN JOAQUIN COUNTY <br />is -.:-- •.Z, <br />U)Q. ."�F� -t ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />gC,FORN <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facilit Name: <br />�Q� <br />Inspection D te: <br />XDl l7 f <br />Facility A s: <br />Service Request #: <br />Onsite Service Technician's Nam <br />ICC Ser, cion/Installer Exp. Date: <br />Manufacturer Training: <br />4ceech <br />ll� <br />❑ <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 <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <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 950,10 <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 />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />iillld M1,19W <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 />Other: see below sle e <br />LTJ This UST facility is NOT APPROVED to operate <br />' I I / I=51� <br />rd V.01 21111911FAMW WE Wovow. <br />AWN <br />'74 "2111RIWA <br />2,16,11111 MCI, =P7, <br />iillld M1,19W <br />Z/. N iii. �� �� v <br />_- . �. <br />-I <br />- I��. _ <br />mm� <br />3 / <br />Rev 1 <br />Rev 4//30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />