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SAN JOAQUIN COUNTY Q: a ENVIRONMENTAL HEALTH DEPARTMENT N 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd TQC, 0RN�P UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facil' ame: �'` Inspection Date: Fac yAddress: / Service (Request #: Onsite Service Tec ian's at e ICC Service Technician/Installer Exp. Date: Manufacturer Training: %u; ❑ -(Z' U -lam SERVICE 011 Leak detector �,,,`,� ❑ I mechanical Model: — /11u1i electronic Serial #: 11111091 ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: Title: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA rE1 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 SERVICE 011 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 EHD Inspector: ❑ Caldwell System ❑ Other Title: 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 21 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection rE1 Other: see below ❑ This UST facility is NOT APPROVED to operate EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10 011 ex� e - /41 THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspector: Received B / Title: EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10