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OQ`Q1.111y C SAN JOAQUIN COUNTY 2j-4 G ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 ,P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or /q ehd A�tFOR�` UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT FacM-4tNt", me: Inspection Date: ❑ nW-r�p <X—Z-Z-I Facility Address: Service Request #: ❑ line test programmed ,lam Onsite Service echnician's Name: z ICC Service Technician/Installer Exp. Date: Manufacturer Training: ❑ electronic Serial #: ❑ SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ,lam Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed EHD Inspect sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) ,`97 This UST facility is APPROVED to operate SERVICE Spill bucket .krninimum 5 gallon & 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spil bucket -9 minimum 5 gallon ,lam �;b1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi EHD Inspect minutes ed Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate 117 — EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10 6 THIS FACILITY IS SUBJECT TO REINSPEqTlOq AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspect R� ed Tjtlp: 117 — EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10