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oP`��IN• c <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Q: •;a <br />wn { 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />.. <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />hi <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: I <br />Faciffitg Adailis&Service <br />; `�� <br />Request #: <br />' <br />Onsite Service Technician's Name: <br />ICC Service TechniciantinslPer exp. ate: <br />Manu acture Training: <br />tr� <br />❑ mechanical <br />Model: <br />l Ja-I6WJ <br />This UST facility is APPROVED to operate <br />9 <br />Ill 1/%'%air%■Wr A% !W Perms <br />S RVICE <br />S <br />R CE <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical <br />Model: <br />❑ <br />❑ electronic <br />Serial #: <br />❑ Caldwell System ❑ Other <br />❑ line test programmed <br />Prir ry piping testing at: ' S� - PAevW N- <br />Leak detector <br />psi 15 3 111V. �� <br />mechanical <br />Model: i -P 2t0 <br />ting <br />Secondary containment to f r: ) r1t, <br />electronic <br />Serial #: <br />❑ <br />❑ line test proqrammed <br />sensor <br />& Fwf- k <br />❑ <br />❑ positive shutdown <br />Model: <br />❑ <br />❑ fail safe <br />Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown <br />Model: <br />❑ fail safe <br />Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown <br />Model: <br />❑ fail safe <br />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 />9 <br />Ill 1/%'%air%■Wr A% !W Perms <br />S RVICE <br />t` M81, - 0� �� .' _IN G. 1 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />SUBJECTWal <br />THIS FACILITY IS Lp�6,J.7EHD'S CURRENT HOURLY RATE. <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Prir ry piping testing at: ' S� - PAevW N- <br />❑ <br />psi 15 3 111V. �� <br />m <br />�2inutes <br />ting <br />Secondary containment to f r: ) r1t, <br />UDC(I Piping Si <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 20 contain Hent components are required to be tested upon <br />installation, 6 months after, and every 6 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 />i <br />t` M81, - 0� �� .' _IN G. 1 <br />a MN <br />SUBJECTWal <br />THIS FACILITY IS Lp�6,J.7EHD'S CURRENT HOURLY RATE. <br />41V <br />EHD 23-04 �—� U v r v UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />