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OP'•4uIN'•.0 <br />Inspection Date: <br />Leak detector <br />SAN JOAQUIN COUNTY <br />Q. + <br />W. <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />❑ electronic Serial #: <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />Onsite Service Technician's Name: <br />WC Service Technicia Insta a Exp. Date: <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Leak detector <br />❑ <br />Facility Address: <br />Service Request #: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT AW TIME AT EHD'S CURRENT HOU RATE. <br />Onsite Service Technician's Name: <br />WC Service Technicia Insta a Exp. Date: <br />Manufacturer Training: <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT AW TIME AT EHD'S CURRENT HOU RATE. <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 />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <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 />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT AW TIME AT EHD'S CURRENT HOU RATE. <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 />Note: Please be aware that 21 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 />Corrosion protection <br />❑ <br />Other: see below <br />X This UST facility is NOT APPROVED to operate <br />e Y1' d • b <br />31 / = <br />iwdedO - �aal&n cqjqLmM <br />8 —7 U9 e Con i.l' <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT AW TIME AT EHD'S CURRENT HOU RATE. <br />EHD Ins ector: <br />Received By: / <br />Title: <br />EHD 23-04fjo <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />