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OP.Q V I N. <br />SAN JOAQUIN COUNTY <br />Q' ENVIRONMENTAL HEALTH DEPARTMENT <br />I � <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />9<%FORS <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />I � <br />Dec- <br />Facility Address: <br />Service Request #: <br />1,1-3,,5 <br />-:5Y20?D,60`1l 35 - <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacty rTraiX— <br />ng: <br />❑ <br />❑ mechanical Model: <br />((5�/ <br />SERVICE <br />C ,e� 4i,5r t.- a- 7 7 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />t e— <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Re ive By: <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />rETIOver-fill <br />prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />C ,e� 4i,5r t.- a- 7 7 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />t e— <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />Re ive By: <br />minutes <br />Title: <br />Secondary containment testing for: <br />,4 '7UDC(s) powA—f 4-u,i2 Piping <br />Sump(s) UST(s) <br />Testing fortheabove 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 />n,s14 £I F)--7hii --.>,,I1 <br />EHD 23-04 <br />Rev 10/06/10 <br />V UST SERVICE REQUEST INS`pECTION DEPORT <br />C ,e� 4i,5r t.- a- 7 7 <br />r-1 r- - <br />e- Lopl.4�� h <br />t e— <br />— 7 ,.c- k--g--f-- 0ayLA4 <br />THIS FACILITY IS SUBJECT TO htINSPECTION A <br />09 <br />ANY TIME AT EHD' CURRENT HOURLY RATE. <br />EHD Ins or: <br />Re ive By: <br />Title: <br />EHD 23-04 <br />Rev 10/06/10 <br />V UST SERVICE REQUEST INS`pECTION DEPORT <br />