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OP�u IN'• C <br />" °G SAN JOAQUIN COUNTY <br />e: �+ ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.slgov.org/ehd <br />�;FORa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Nae: <br />Inspection Date: <br />Leak detector <br />—1 lL/ <br />Facility Address: <br />35 E, <br />Service Request #: <br />S Us 7& 3 <br />Onsite Service Technician's Name: <br />J �-h a <br />ICC Service Technician/Installer Exp. Date: <br />S — — 1 CQ <br />Manufacturer Training: <br />D` 5�`� is <br />o s ov o,c� l <br />Leak detector <br />7 <br />SERVICE <br />0 k V SA f i --A-Wo kAA�-lutj <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />r -h� u i <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Received B ` <br />n/i <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />❑ <br />Overfill prevention (see LG letter 150-1) <br />This UST facility is APPROVED to operate <br />SERVICE <br />0 k V SA f i --A-Wo kAA�-lutj <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />r -h� u i <br />❑ Caldwell System ❑ Other <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 />Received B ` <br />n/i <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <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 />(f -- <br />Other: see below t -n t -tea <br />❑ This UST facility is NOT APPROVED to operate <br />N IC& Cncin mea <br />0 k V SA f i --A-Wo kAA�-lutj <br />a n Ap t , ric n <br />e r t n -e-5 +, <br />r -h� u i <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspect r: <br />Received B ` <br />n/i <br />Title: �-- <br />% <br />EHD 23-04 <br />Rev 4/30/16q <br />�A A21___ <br />j <br />UST SERVICE REQUEST INSPECTION REPORT <br />