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Rquly • <br />�o.�Ej,coG SAN JOAQUIN COUNTY <br />`y ENVIRONMENTAL HEALTH DEPARTMENT <br />tn.. < <br />.: ". 600 East Main Street, Stockton, CA 95202-3029 <br />.P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />ehd <br />��►FORa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facili <br />ame:Inspeecction <br />t2M3 <br />Leak detector <br />Date: <br />6& — <br />Facility Address: <br />z5 rt -NA <br />Service Request #: <br />O � .77a <br />Onsite Servic Technician's Name: <br />ICC Se 14 Technicianlinstaller Exp. Date: <br />Manufacturer Training: <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />SERVICE <br />�� :;.:ZTill <br />.�_�..ffA11Wi M. <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />IRAN W . Ar.►. <br />❑ electronic Serial #: <br />❑ line test programmed <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 />❑ 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 />�� :;.:ZTill <br />.�_�..ffA11Wi M. <br />ucke S inimum eglon <br />01 hour hydrostatic ❑ Incon TS -STS <br />IRAN W . Ar.►. <br />❑ Caldwell System ❑ Other <br />Spill bucket j2rminimum 5 gallon <br />,B" I 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 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 />11 I !� �1 ��' �� 'r>1>G' ■ . .■ Eli � _ a. --►�./ / <br />�� :;.:ZTill <br />.�_�..ffA11Wi M. <br />MERRMA <br />rA JL <br />-TAFAMA IN MA - <br />IRAN W . Ar.►. <br />Lei `, <br />v v - <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />