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AqutN. XoSAN JOAQUIN COUNTY <br />.�.co <br />*ENVIRONMENTAL HEALTH DEPARTMENT <br />Ni 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />ORS <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Leak detector <br />Inspection Date: <br />—0PV;1 0— <br />C �(.� �� 5 <br />❑ electronic Serial #: <br />46 .— 26 — / 3 <br />Facility Address: <br />❑ <br />Leak detector <br />Service Request #: <br />3Li3 4 <br />❑ electronic Serial #: <br />_-5�12-Do 6 `7 Lk 1 <br />Onsite Servi a Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />1 '/-/r- <br />Manufacturer Training: <br />tl Iq <br />o",6 1 <br />% <br />a, 13 . <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSP CTION 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 />positive shutdown Model: <br />❑ f I safe Serial #: <br />A <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSP CTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 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 />E H D 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/ <br />THIS FACILITY IS SUBJECT TO REINSP CTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins ctor: ceived <br />Title: <br />.j <br />E H D 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/ <br />