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Facility Name: _ SAN JOAQUIN COUNTY ❑ mechanical Model: ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Facility Address: I Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orglehd aL1 FORS Service Technician's Name: UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: Traw ❑ mechanical Model: A- 0 Facility Address: I raw Service Reque t #: 241, U In)Onsite Service Technician's Name: Leak detector ICO Service Technicibrifinstaller fxp. Date: I Ma�1 cturer Trainin ( ❑ electronic Serial #: ❑ ❑ line test programmed SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate 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 UST facility is NOT APPROVED to operate I V THIS FACILITY IS SUBJECT TO REINSPECTJON ATANY TIME AT EHD'S CURRENT HOURLY RATE. I EHD 23-04 (� " UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10