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OPQ�.I.N. C <br />>.• <br />SAN COUNTY <br />�''•.o <br />.IOAQUIN <br />¢- ,, y.+ <br />W.-600 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />East Main Street, Stockton, CA 95202-3029 <br />❑ line test programmed <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />9��FOR� <br />Onsite Service T nician'Nam@: <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />F Ility Name: <br />��S <br />SERVICE <br />q <br />- V� � G�✓ I <br />Inspection Date: <br />� ' �i -tl <br />Facility Address: <br />11 A <br />Service. Request 11: <br />❑ line test programmed <br />Leak detector <br />Onsite Service T nician'Nam@: <br />❑ mechanical Model: <br />ICC Service Tech nicianllinstal ler Exp. Date: <br />Manufacturer Training: <br />Q�A,"',L <br />❑ line test programmed <br />- - �- <br />UW - <br />/10 This UST facility is APPROVED to operate <br />SERVICE <br />Leak detector <br />mechanical Model: a <br />❑ <br />❑ electronic Serial #: 10i1101'11 <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <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 />/10 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 />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 />A�j 12 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: A n Recei- By. Title- <br />-1 <br />EHD 23 04 I IST SFRVICF RFOI IFST INSPECTION REPO <br />Rev 10/06/10 <br />