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Ru l SAN .I®AQUIN COUNTY ;G ENVIRONMENTAL HEALTH DEPARTMENT { 600 East Main Street, Stockton, CA 95202-3029 F. P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd � ti�oRc' UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: TG& M-M-2zlil Facility Address: Service Request #: ❑ electronic Serial #: Onsite Service Techn is % Nam ICC Service Tech ician/ staller Ekp. Date: Manufacturer Training: Leak detector ❑ SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed affi�vrsor ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ III or ❑ Model: positive shutdown ❑ ❑ fail safe Serial #: VLRDAGj ❑ ❑ NA ❑ 90pmor In positive s utdown Model: 1�q ❑ fail safe Serial* I ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes 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 US facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate EHD 23-04 Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT