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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT y4�llt < 600 East Main Street, Stockton, CA 95202-3029 �• .P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd 0 UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name:r Cen-tv- CA-- M Inspectio L12-11201,-? :'SLkee ❑ ❑ mechanical Model: Facility Address: q0 [ C a Y+R r S -+o -k4 tn" Service Request #: P- U 65 13 2 Onsite Service Technician's Name: J (-� ICC Service Technician/Installer Exp. Date: Manufacturer Training: SERVICE .i.. Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: • • • ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA KTesting sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate SERVICE .i.. J�jSpill bucket ❑ minimum 5 gallon / V,1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other • • • Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) KTesting for the above components are next due by: Note: Please be aware that 21 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection Other: see below ❑ This UST facility is NOT APPROVED to operate i .i.. FIX &Z./I.i / ,, r r • • • WW-110JI&I �04e EHD 23 04 Vv O V / Rev 10/06/10C::�� UST SERVICE REQUEST INSPECTION REPORT