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SAN JOAQUIN COUNTY s� ENVIRONMENTAL HEALTH DEPARTMENT l 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Fact' Name(:: Inspection Date: ❑ L1 �� Facility Address: Service Re est #: ❑ ' l ��o �. ` ,5 J i u � Onsite Service Technician's Na ICC Service Technician/Installer Exp. Date: -7 Manufacturer Training: �n �� tc - I - , - I� �� v ) -Li-jcr SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA 54. sensor ❑ ❑ positive shutdown Model: Received By: ❑ fail safe Serial #: Titled: ❑ 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 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other 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: Note: Please 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 54. Other: see below ❑ This UST facility is NOT APPROVED to operate EHD 23-04 d UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12 VMLIh J m THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. EHD Inspector: Received By: Titled: EHD 23-04 d UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12