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AgUI(y SAN JOAQUIN COUNTY Q: a ENVIRONMENTAL HEALTH DEPARTMENT N._ { 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Na Inspection Date: cc? (^7,7-% f7—' Facility Address: Service Request #: Onsite Service Technician's Name: ICC Servic6 Technician/installer Exp. Date: Manufacturer Training: %-3-1 ❑ Leak detector ❑ SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: THIS CI PTY IS UBJECT TO REINSP I HD'S CURRENT HOURLY RATE. ❑ 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 ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ 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 THIS CI PTY IS UBJECT TO REINSP I HD'S CURRENT HOURLY RATE. 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 VA Sumps) UST(s) Testing for the above components are next due by: Note: Please 9 aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below _-Q] This UST facility is NOT APPROVED to operate C r, S i. fG THIS CI PTY IS UBJECT TO REINSP I HD'S CURRENT HOURLY RATE. EHD Ins o e Title: L/ EHD 23-04 Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT