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PQuIN ' <br />�o..coG SAN .IOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.s*gov.org/ehd <br />•4�%FpRti <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />.--7-// <br />❑ mechanical Model: <br />--13-1 <br />Facility Address:(/� <br />Service Request 4 <br />LaZ � i rli� <br />/! 1 <br />Le�'I ax �(�G7 v,� <br />/ / / <br />L� -2 / 0 9 <br />Onsite Service Technician's Name: <br />ICC Service Technician/installer Exp. Date: <br />Manufacturer Training: <br />S <br />FTHIS <br />EHD InsEHD Inspector: <br />-� / <br />VPC <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 />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />FTHIS <br />EHD InsEHD Inspector: <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <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 />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 />Primary piping testing at: <br />❑ <br />psi <br />FTHIS <br />EHD InsEHD Inspector: <br />minutes <br />Title: <br />Secondary containment testing for: <br />All UDC(s) Piping <br />Sump(s) UST(s) <br />Testing for the the above components are next due by: <br />IV /-A <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 />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />RHD 23-04 �� <br />Rev 230/12 J,/ <br />UST SERVICE REQUEST INSPECTION REPORT <br />FACIEltl IS StttJECT <br />TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />FTHIS <br />EHD InsEHD Inspector: <br />R eived B <br />Title: <br />RHD 23-04 �� <br />Rev 230/12 J,/ <br />UST SERVICE REQUEST INSPECTION REPORT <br />