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SAN JOAQUIN COUNTY - - ,� ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 q . `P.• Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or /d ehd p� �iiio ±�® p� pis ppg ® ® ® ®®� REQUEST p� �s UNDERGROUND STORAGE TANK (VST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: 3 Facility Address: Service Request #: 14o t tic ,�.._ 7 Onsite Service Technician's Name: ICC Service T chnician/installer Exp. Date: Manufacturer Training: G f SERVICE I• 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 sensor ❑ ❑ positive shutdown Model: r • ❑ fail safe Serial #: �' 'f ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE I• 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: , s 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 Other: see below ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate EHD 23-0 66/ UST SERVICE REQUEST INSPECTION REPORT Rev 10/06110 I• i i r WWr , s WRillliliiiiiiiiiiiiiiiillillillillilI •` 0�' F, r • ..rte, f../� �' 'f 1� L • 1 EHD 23-0 66/ UST SERVICE REQUEST INSPECTION REPORT Rev 10/06110