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pqu f ry <br />o • "" c SAN JOAQUIN COUNTY 10 <br />2 �rENVIRONMENTAL HEALTH DEPARTMENT <br />e: • a <br />y 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />cq�iFOR��e• <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Facility Address: Service Request #: <br />QJ CA S t2 QOM I� 8 4 <br />Onsitg Service Technician's Name: ICC Service Technician/installer Exp. Date: Manufacturer Training: <br />3�1 4-1 <br />SERVICE <br />1 t lh-e� e (J-!)(, a - ll,-- <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 />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <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 />SERVICE <br />1 t lh-e� e (J-!)(, a - ll,-- <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 />Title: <br />o C-9 �tV <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for- <br />9 &• Q' l <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Testing for the above componentj are next due by: <br />6 N V " L"S10-0 <br />Note: Please be aware that 20 con inment 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 />wb l ve See,O q -cd 91 <br />1 t lh-e� e (J-!)(, a - ll,-- <br />YOt1�rJ <br />4- <br />V1 C1 I -n L'te <br />� t <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />Received By: <br />4�� <br />Title: <br />o C-9 �tV <br />EHD 23-04 <br />Rev 4/30/12 <br />b <br />UST SERVICE REQUEST INSPECTION REPORT <br />