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PquIN <br />�•+E_�o� SAN JOAQUIN COUNTY <br />*NVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205- 232 <br />' Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />q�ikoR�' <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: % <br />7- 1�Lv-- <br />Inspection Date: <br />Z' 7xi( - % <br />Facility Address: <br />Service Request #: <br />On(1�y's`tiel/ a vice Technician' Name: <br />vi Q t�'-I,f67 <br />ICCG Service Technician/Installlerr E}x-p. Date: <br />Manufacturer Training: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI T EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <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 />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI T EHD'S CURRENT HOURLY RATE. <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 />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 20 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 />r 3 r, �, _--• <br />P , <br />ri - L 11 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI T EHD'S CURRENT HOURLY RATE. <br />EHD Inspe <br />/I <br />Rar.01ve By: A <br />wig <br />Title: <br />EHD 23-04 VLj UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />