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pqulN <br />40 r Un T <br />Leak detector <br />SAN JOAQUIN COUNTY <br />2.• _�r�_ :Z <br />ar -+ <br />y. <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232, <br />gCiFpRN <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sipov.org/ehd <br />❑ line test programmed <br />❑ <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />V0M111LY JM011 C. <br />iiii////pppp sC <br />Facility Address: <br />Oma � <br />Onsite Service Technician's Name: <br />,; (04 -so � h Sm(1 <br />,, C. <br />Ci- r. <br />ICC Service Technician/Installer Exp. Date: <br />SERVICE <br />40 r Un T <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />-�° <br />-) 0 l� v K 12 <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />X1.0. ? sensor <br />� <br />11 positive shutdown Model: _ q0 4" <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: _ <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />K <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 />Inspection te: // ® /2614 <br />Service Request #: <br />SP D®; -I( <br />Mafniuf�tur�iTraining: C /. Vt�:51,�>7,���� <br />SERVICE <br />40 r Un T <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />-�° <br />-) 0 l� v K 12 <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 />� <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 />K <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />k 1e-- n <br />40 r Un T <br />e,���-�- --�o ►.� <br />o -��- -L-0 <br />6r1 <br />-�° <br />-) 0 l� v K 12 <br />rye ev pis o <br />THIS FACILITY IS SUBJECT TO REINS CTION <br />T NY TIME AT END'S CURRENT HOURLY RATE. <br />EHD Ins ctor: <br />&, <br />Re 'v d <br />� <br />Title: <br />EHD 23-04 yj a UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />