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op4utN ° SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />m. X118 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />i P . Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Leak detector <br />Inspection Date: <br />❑ mechanical Model: <br />r -:h-- -70 <br />❑ electronic Serial #: <br />--a-7— <br />Facility Address: <br />❑ <br />Leak detector <br />Service Request #: <br />CoLi acS N. ?ac, Sc. <br />Aw—I +vcic <br />C- <br />'l&11C,l <br />Onsite Service Technician's Name: <br />Ic <br />ICC Ser e Technicia <br />�- <br />Installer Exp. Date: <br />Manufacturer Training: M Ccn <br />ApT (n -13-t5 ;P-.tP?-i7 <br />chola ( <br />1-20-1-1 <br />-' i- I IS <br />„ SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />o <br />❑ electronic Serial #: <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 />❑ fall safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />El❑ <br />positive shutdown Model: <br />❑ fall 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 />yThis UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />o <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Title: <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />enk Sump(s) UST(s) <br />Testing for the above components are next due by: <br />,A%4 8 1,C.>, 0-01 IS <br />Note'. Please be aware that V containment components are requil 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 />P <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />S .k —hoO C <br />C0 %\ ,-Ai e <br />S� <br />o <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EH Inspector: <br />Received By: <br />Title: <br />EHD 23-04 L7 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />