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PqutN. SAN JOAQUIN COUNTY <br />NVIRONMENTAL HEALTH DEPARTMENT 6 <br />�IY6 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />F. <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si-ov.org/ehd <br />A�/FiiRa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />AmlPm <br />❑ <br />Facility Addr s: <br />Service Request #: <br />/ <br />TH,W-PACILITX IS SUBJE T TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training:(_._ -;� --Z c <br />A� <br />12-20! <br />SERVICE <br />c 40 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />TH,W-PACILITX IS SUBJE T TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />J <br />SRRVfK <br />c 40 <br />Spill bucket _U minimum 5 gallon <br />`� <br />X31 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ."'OtherV „�; z, Q r1 <br />TH,W-PACILITX IS SUBJE T TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />1.. <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 21 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 />cse -5 'J <br />c 40 <br />TH,W-PACILITX IS SUBJE T TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD In or: <br />Receiv y <br />Title: <br />I M, <br />EHO 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />