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Aqu1N <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />•.y <br />N ` 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />AL�FOR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />C '7 <br />-;?---1 -2-- <br />Facility Address: <br />Service Request #: <br />6 <br />Onsite Service Technician's Na e: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ <br />6 <br />\/R f D <br />%,.,I J <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />rbl <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />tal L. / <br />R -1 y 1 sensor <br />VWEl <br />positive shutdown Model: go <br />�S <br />❑ fail safe Serial #: <br />aS (G <br />NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />TE. .:Q <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 />rEl <br />Overfill prevention (see LG letter 150-1) <br />7 This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />rbl <br />Primary piping testing at: <br />❑ <br />psi <br />tal L. / <br />minutes <br />Secondary containment testing for: <br />�S <br />UDC(s) Piping <br />aS (G <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />S N <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 />THIS FACILITY IS SUBJECT TO <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 �- <br />Rev 10/06/10 <br />5004 <br />v d UST SERVICE REQUEST INSPECTION REPORT <br />4�y <br />rbl <br />tal L. / <br />— ?;-7 <br />�1 dl <br />�S <br />1 50►� <br />aS (G <br />/nnfit <br />124-y-4-- <br />S N <br />gyp, ,jCl <br />��5vtv <br />l""s �LlC(��/' %C3'� =�`! <br />_ ��3�1 '�Cc <br />] <br />_ Aj � /(v C <br />THIS FACILITY IS SUBJECT TO <br />EINSPECTION AT ANY TIM9 AT EHD'S CURRENT HOURLY <br />TE. .:Q <br />EHD Inspect <br />Received By: <br />Title: <br />EHD 23-04 �- <br />Rev 10/06/10 <br />5004 <br />v d UST SERVICE REQUEST INSPECTION REPORT <br />