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Pp U l /y <br />SAN JOAQUIN COUNTY <br />_�r y ENVIRONMENTAL HEALTH DEPARTMENT <br />Q: a <br />y ` 600 East Main Street, Stockton, CA 95202-3029 <br />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 />Inspection Date: <br />(� <br />Imo Dp�a cr <br />77 '��� <br />t.C- 2-' / <br />Facility Address: <br />Service Request #: <br />❑ electronic Serial #: <br />W1`171— (� <br />Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />6e <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />%'3 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />� <br />❑ electronic Serial #: <br />W1`171— (� <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 />THIS FACILITY IS <br />❑ NA <br />❑ <br />sensor <br />❑ <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 />❑ NA <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 />Ai5 This UST facility is APPROVED to operate <br />SERVICE <br />%'3 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />� <br />❑ Caldwell System ❑ Other <br />W1`171— (� <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />I,^ <br />r <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />LAI 112- <br />Secondary containment testing for: <br />UDC(s) Piping <br />THIS FACILITY IS <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please 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 �/ <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />%'3 <br />o <br />� <br />W1`171— (� <br />L. — l (7 3/ <br />— 76K "— Z <br />(l fi— <br />I,^ <br />r <br />LAI 112- <br />41, <br />THIS FACILITY IS <br />SUBJECT TO REINSPE <br />TION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD In or: <br />Received By: <br />c <br />Title: <br />5-A <br />EHD 23-04 �/ <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />