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O Pa U I N• •.0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />• c .. Q <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.org/ehd <br />9��FORN <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />- L <br />Inspection Date: <br />❑ <br />a4 - <br />Facility Address: <br />Vd , �S e <br />Service Request #: <br />Sl*2 00 (eq q q <br />Onsite Service Technician's Name: <br />Leak detector <br />ICC Service /Installer Exp. Date: <br />Manufacturer Training: <br />CVP (; C.if�Ge+— <br />❑ electronic Serial #: <br />q ,cL� <br />❑ line test programmed <br />SERVICE <br />- L <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY SUBJECT TO REINSPECT11014 AT ANY TIME AT EHD'S CURRENT HO RLY RAT . <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 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 />- L <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY SUBJECT TO REINSPECT11014 AT ANY TIME AT EHD'S CURRENT HO RLY RAT . <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 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 31 rd a ti rQ l C Uw <br />❑ This UST facility is NOT APPROVED to operate <br />�L <br />EHD 23-04 UST SERVICE RE UEST INSPECTION REPORT <br />Rev 4/30/12 <br />- L <br />r � <br />THIS FACILITY SUBJECT TO REINSPECT11014 AT ANY TIME AT EHD'S CURRENT HO RLY RAT . <br />EHD Inspe91e5 / <br />v <br />Receivy: <br />/ <br />�L <br />EHD 23-04 UST SERVICE RE UEST INSPECTION REPORT <br />Rev 4/30/12 <br />