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I <br />'oPQu l,N,•,.co <br />SAN JOAQUIN COUNTY 46 <br />Q� `� ENVIRONMENTAL HEALTH DEPARTMENT <br />y. l I x <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />Q�hi0ORS �p STORAGE <br />® ® pp ®�/ <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: / <br />Inspection Date: <br />20 U <br />aaj� `Shp <br />Facility A dre <br />[VX <br />Service Request #: <br />_2'�Kjqo I\j <br />(2 <br />Onsite Service Technici n's Name: <br />IPICCSe 'ce Te hnicia Installer Ex Date: <br />Manufacturer Training: f <br />Jamechanical Model: ®D(�_ <br />SERVICE <br />! t1 Wo 1 p.:'..L1I'.' <br />Leak detector <br />❑ <br />mechanical Model: W LD3000 <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />P!9, Leak detector <br />Jamechanical Model: ®D(�_ <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 />11ttz7��a�ii.ut�ssi✓�.ii. r+2111111111nar.+.WA' <br />SERVICE <br />! t1 Wo 1 p.:'..L1I'.' <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 />..�.✓�NO <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 />,Fe' This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br />�r� 1.4f -U 14. N I 4-n ra J, <br />FU <br />! t1 Wo 1 p.:'..L1I'.' <br />IIIVWZ <br />AZ / I <br />L4E4Ce —, <br />..�.✓�NO <br />EHD 23-04 v l v UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />