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oAquly c <br />• <br />�.•E •.o� <br />SAN JOAQUIN COUNTY <br />Q y-, <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />. <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />0 <br />❑ <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility ame: <br />Inspection Date: <br />Facility Address: <br />Service Request #: <br />// <br />/ �( <br />Onsite Service Technician's Name: <br />ICC Tervice Technician/Installer Exp. Date: <br />-M-ann'ufacturer Training: <br />L <br />l <br />This UST facility is APPROVED to operate <br />3 <br />SERVICE <br />;v -t yam. 1N fi" t <br />SERVICE <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />I pak rintcrtnr <br />❑ <br />❑ me <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ ele <br />❑ Caldwell System ❑ Other <br />El <br />me <br />Primary piping testing at: <br />El <br />psi <br />❑ ele <br />minutes <br />El <br />5" UDC(s) 3-7 Piping <br />Sump(s) UST(s) <br />Testing for the above components are next due by: <br />❑ fail <br />�ZoiyL��r� �7 <br />❑ NF <br />❑ <br />❑ <br />❑ <br />❑ fail <br />10 <br />Other: see below <br />❑ NA <br />3. <br />. __ <br />❑ po <br />7. <br />El= <br />❑ fai' <br />�. <br />❑ NF <br />at 95% <br />at 95% <br />❑ <br />❑ <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />This UST facility is APPROVED to operate <br />3 <br />SERVICE <br />;v -t yam. 1N fi" t <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPEC ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 />Secondary containment testing for: <br />5" UDC(s) 3-7 Piping <br />Sump(s) UST(s) <br />Testing for the above components are next due by: <br />�ZoiyL��r� �7 <br />Note: Please be aware that 21 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 />w <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />;v -t yam. 1N fi" t <br />LA <br />THIS FACILITY IS SUBJECT TO REINSPEC ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EFiD Inspector: <br />Received By: <br />Title: <br />w <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />