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'o�qulh•c -.EE'•.oG Q •� ��FORa SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: V -f ❑ mechanical Model: Facility Address: i Service Request #: ❑ Leak detector ❑ Onsite Service Technician's Name: I C Service Technician/Installer Exp. Date: Mandfacturer Training: ,4--, 3 i ❑ SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: i ❑ 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 at95% F-1 Droptube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate SERVICE > Spill bucket rlinimum 5 gallon --hour -R9hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other i Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS Received By: ❑ 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: Note: Please be 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 ❑ This UST facility is NOT APPROVED to operate EHD 42.9[ r r �+ \ UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/1: \I I i T A ILIT iS SUBJECT TO REINSPECTIO At ANY TIME AT END'S CURRENT HOURLY RATE. EHD pe Received By: Title: EHD 42.9[ r r �+ \ UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/1: