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'O PQU t/y cO <br />Z.• ��r� :Z SAN JOAQUIN COUN'T'Y <br />c :-+ ENVIRONMENTAL HEALTH DEPARTMENT <br />H. X <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />• `P•� <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj og v_or /g ehd <br />O <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVILE REQUEST <br />EST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />f f(0 -0 16 - <br />Facility Address: Service Request #: <br />Technician's Name: ` ICC Servicer Ti <br />o _t dI <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />mechanical Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: <br />Spill bucket ❑ minimum 5 gallon <br />❑ line test programmed <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Leak detector <br />❑ Caldwell System ❑ Other <br />mechanical Model: C�Z <br />Primary piping testing at: <br />❑ electronic Serial #: ft Q10 i 1 <br />psi <br />❑ line test programmed <br />minutes <br />[36XV0 sensor <br />Secondary containment testing for: <br />❑ positive shutdown Model: /lA <br />UDC(s) Piping <br />fail safe Serial #: A/A- <br />Sump(s) UST(s) <br />NA <br />Testing for the above components are next due by: <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Cold start of monitoring panel <br />❑ fail safe Serial #: <br />Corrosion protection <br />❑ NA <br />Other: see below <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 />A/Installer Exp. Date: Manufacturer Training: <br />A I ®+ rlai <br />SERVICE <br />Xf This UST facility is APPROVED. operate 0 This UST facility is NOT• to operate <br />� '' ��� � r'; ��'�.Il��.--iii''r.�����—s��y�ac�ir�•„��<aa+[ � r,� .� �` <br />KIMj <br />111\'` ��I r 7, • C [ #I�V���' ll� <br />53 <br />a <br />THIS FACILITY IS SUBJECT TO REINSPECTIQPfAT#NY TIME AT EHD'S CURRENT HRLY RATE. <br />EHD Inspec or: Received Title: _QU <br />4 <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <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 />❑ 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 />Xf This UST facility is APPROVED. operate 0 This UST facility is NOT• to operate <br />� '' ��� � r'; ��'�.Il��.--iii''r.�����—s��y�ac�ir�•„��<aa+[ � r,� .� �` <br />KIMj <br />111\'` ��I r 7, • C [ #I�V���' ll� <br />53 <br />a <br />THIS FACILITY IS SUBJECT TO REINSPECTIQPfAT#NY TIME AT EHD'S CURRENT HRLY RATE. <br />EHD Inspec or: Received Title: _QU <br />4 <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />