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tRu!N, <br />?�'��''•..a 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.sigov.org/ehd <br />.�tjiwo'• •. <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />'i Leak detector E T <br />mechanical Model <br />❑ <br />Facility Address: <br />Service Request #: <br />leu <br />�. <br />Onsite Service Technici n's Name: <br />ICC Se ice Technician/Installer Exp. Date: <br />Manufacturer Training: <br />'ll -)Jo 1 <br />0-A i.. Vm -� �1- <br />SERVICE <br />'i Leak detector E T <br />mechanical Model <br />❑ <br />❑ electronic Serial* o130 <br />1 �1 <br />❑ line test programmed <br />( ' Lj ,ryJp <br />CAI Leak detector�� R <br />❑ <br />echanical Model: <br />❑ electronic Serial #: <br />'94 <br />❑ line test programmed <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />oe. Q), <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 />1 �1 <br />❑ Caldwell System '❑ Other <br />( ' Lj ,ryJp <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />'94 <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 />oe. Q), <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 />XThis UST facility is NOT APPROVED to operate <br />16 <br />EHD 23-04 (J�S Q \ %0 -), UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />1 �1 <br />( ' Lj ,ryJp <br />rf,'3(' <br />15\ <br />'94 <br />(c <br />( <br />vac4ori <br />os� a o <br />,�. <br />tk - <br />oe. Q), <br />THIS FACILITY IS <br />UB CT TO EINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Insp�er�tor: <br />Received B . <br />Title_ <br />16 <br />EHD 23-04 (J�S Q \ %0 -), UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />