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OPQuIN• <br />• <br />Q <br />�' '' ° <br />SAN JOAQUIN COUNTY <br />;- <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />9�f1=0R� <br />Telephone: 209 468-3420 Fax: 209 468-3433 Web: www.sigov.org/ehd <br />Q. <br />❑ <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facilit_ y Name: <br />A <br />Inspection Date: <br />Facility Address: I <br />�0 A T <br />Service Request #: <br />q� <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Expl Date: <br />Manufacturer Training: <br />L <br />Q. <br />❑ <br />SERVICE <br />64, lad io <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />L <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />R <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 />❑ This UST facility is APPROVED to operate <br />SERVICE <br />64, lad io <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />L <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 />R <br />minu es <br />Title: <br />econdarycontainment estln or.: ; hav15 <br />UDC(s) ft14W4 Piping <br />Sump(s) ` <br />Testing for the above components are next due by: <br />14' C-64 66w1 <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 />Other: see below <br />This UST facility is NOT APPROVED to operate <br />1 <br />3 <br />EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 Ci <br />64, lad io <br />C t <br />L <br />T <br />10 <br />THIS FACILITY IS SUBJECT TO REINS <br />CTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins or: <br />R <br />eived By: <br />Title: <br />1 <br />3 <br />EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 Ci <br />