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OPquIN ?•--•+F1''••a� SAN .IOAQUIN COUNTY w .l 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd P UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: — QV Insection Date: �q— Facility Address: 1�' rn Vili Service Request r -S #: Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: ..� C� Manufacturer Training: _(M) r - I -r I OPIV SERVICE fD d5a rs& - 1il 0 �Q� Leak detector ❑ ❑ mechanical Model: f SC' f64 alLi ❑ electronic Serial #: ❑ 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 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 fD d5a rs& - 1il 0 �Q� Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS f SC' f64 alLi ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS Received By ❑ 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: NotePlease 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 Other: see below ❑ This UST facility is NOT APPROVED to operate us)4p fD d5a rs& - 1il 0 �Q� P ona f SC' f64 alLi DQ * cc) ns THIS FACILITY IS SUBJECT TO REINSPECTIO AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EH ect Received By Title: EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT