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SAN JOAQUIN COUNTY a ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 WeWeb:www.s*qov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: 0�) �Qcot SERVICE Inspection Date: ru Spill bucket ❑ minimum S t X19 ❑ ❑ mechanical Model: Facility Address: n / ��/� p Mouhoc ServiceRequest vi #: (r / Onsite Service Technician's Name: ICC Service Technician/InstallerExo_Date: Manufacturer Training: Jc-:�,(ToY- 0 Leak detector ❑ This UST facility is APPROVED to operate SERVICE SERVICE Spill bucket ❑ minimum Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: Spill bucket ❑ minimum ❑ line test programmed ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ psi ❑ line test programmed minutes sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA _ _ sensor ❑ ❑ positive shutdown Model: installation, 6 months after, and every 36 months thereafter. ❑ fail safe Serial #: Cold start of monitoring panel ❑ NA Corrosion protection EHD Inspector: 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 This UST facility is NOT APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 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) ❑ Testing for the above components are next due by: Note: Please be aware that 20 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel REINSPECTION AT ANY ❑ Corrosion protection EHD Inspector: Other: see below .: This UST facility is NOT APPROVED to operate EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPOR Eve WIN 40 pal THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY EHD Inspector: .: EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPOR