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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ��•-. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: Facility Address: Service Request #: Onsite Service Technician's Name: ICC Gervice Technician/Installer Exp. Date: Manufacturer Training: coli _oA ec� `t -IS n 0v SERVICE 'b'V1 C� : Leak detector ❑ ❑ mechanical Model.- odel:❑ Elelectronic Serial #: coli _oA ec� `t ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: X ❑ electronic Serial #: ❑ line test programmed EHD Ins' C tf�n � sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA 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 'b'V1 C� : Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other coli _oA ec� `t Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other X Primary piping testing at: �30 psi minutes EHD Ins' C tf�n � 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 ❑ Corrosion protection ❑ Other: see below L This UST facility is NOT APPROVED to operate 1Q �t 5 'b'V1 C� : S' e '7Al d C e' wu coli _oA ec� `t I,N1 `11 THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. EHD Ins' C tf�n � Received By: Title: EHD 23-04UST SERVICE REQUEST INSPECTION REPORT �A Rev 4/30/12 Q