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OPQUIty C <br />). ...�E'•.O <br />2.• r-er , i _ SAN JOAGIUIN COUNTY <br />a -+ ENVIRONMENTAL HEALTH DEPARTMENT <br />W. <br />> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />• _ Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigoy.orq/ehd <br />A�+FORa` <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />)-av <br />—0 - I <br />Facility Address::1 <br />Service Request #: <br />-33-5-15 15�F(hMfLr 1��►`e^ L i ce._ CA <br />CDV �-J <br />Onsite Service Technician's Name: <br />ICC Service Techniclafdlnstaller Exp. Date: <br />Manufacturer Training: <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />EHD I <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 />'Ef 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 i <br />Secondary containment testing for: <br />UDC(s) Piping <br />75-7 1 sum (S) UST(s) <br />Testing for the above componentt are nextfdue b) <br />- e,;Ie- - <br />EHD I <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 />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />r <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD I <br />Receiv By: <br />Title: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />