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SAN JOAQUIN COUNTY <br />• :---cry— : � Z <br />Q' ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />• ,.P Telephone: (209) 4683420 Fax: (209) 468-3433 Web: www.slgov.or /q ehd <br />q�iFoR�� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name- <br />Leak detector <br />Inspection Date: <br />kul <br />GCC j & 2014 <br />(AilK <br />i, <br />Facili y A dress: <br />y <br />$. y <br />Servin equest #: <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />Onsite vice Technicia fs[Jame: <br />ICC Service' iechnicianflnstaller Exy. Date: <br />It G <br />Manufacturer Training: <br />❑ <br />❑ positive shutdown Model: <br />.- � !-, <br />Om <br />❑ NA <br />❑ <br />sensor <br />❑ positive shutdown Model: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />GCC j & 2014 <br />❑ electronic Serial #: <br />F I, <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 />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />- <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 />Spill bucket minimum 5 gallon <br />F= W 1= L) <br />y101 hour hydrostatic ❑ Incon TS -STS <br />GCC j & 2014 <br />❑ Caldwell System ❑ Other <br />F I, <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Received By <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: Is, ' <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; Plyase 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 />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 ' UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />kk.., <br />F= W 1= L) <br />%0- Boom <br />GCC j & 2014 <br />F I, <br />THJ;S FACILITY IS SUB4EC,T TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspeptor; <br />Received By <br />Title.; <br />EHD 23-04 ' UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />