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SAN JOAQUIN COUNTY <br />Q: i •a :NVIRONMENTAL HEALTH DEPARTMENT <br />y._� >11 { 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />Cq�! FF OR�`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />46L �, <br />���te <br />Facility Address: <br />Service Request #: <br />1ti YGi.ve 10a'V t C_C-A' <br />SPI -06 6 �6 f <br />Onsite Service T chnician's Name: <br />[CC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />v✓ CW <br />/ <br />C l 1 <br />SERVICE <br />(/1CJl 720 M t 1 �, <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 />Recei <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 />❑ <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 />(/1CJl 720 M t 1 �, <br />G t Spill bucket IR minimum 5 gallon <br />CR <br />4 71—hour hydrostatic ❑ Incon TS -STS <br />IXCaldwell 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 />Recei <br />minutes <br />Title: <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 20 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 />❑ <br />Other: see below <br />D� This UST facility is NOT APPROVED to operate <br />J SYy <br />(/1CJl 720 M t 1 �, <br />THIS FACILITY IS SUBJECT TO REINSPECT <br />JON AT A,NY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />Recei <br />By:4 - <br />Title: <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />