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oQQ�I�• c SAN JOAQUIN COUNTY 40 ENVIRONMENTAL HEALTH DEPARTMENT y ` 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: ❑ ❑ mechanical Model: l n-7 1 ►q -pi -e -55-'r— 97'• j o s X Facili Address: T F ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. Service Request #: Recei ed By: (, Leak detector ❑ Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: l3 r ❑ ❑ positive shutdown Model: SERVICE Leak detector ❑ ❑ mechanical Model: l n-7 1 ►q -pi -e -55-'r— 97'• j o s X ❑ electronic Serial #: T F ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ line test programmed Recei ed By: (, 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 ':01 hour hydrostatic ❑ Incon TS -STS l n-7 1 ►q -pi -e -55-'r— 97'• j o s X ❑ Caldwell Sy st m ❑ Other T F ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. t Recei ed By: (, Spill bucket ❑ minimurill 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: li,-2— Z�z2psif (cQiS�+s�- 516 �— minutes y� �,� P,5110— 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 day ger t y,l �- >,-t 4-) ❑ This UST facility is NOT APPROVED to operate EHD 2 Rev 10/0B/ 7 /1 UST SERVICE REQUEST INSPECTION REPORT l n-7 1 ►q -pi -e -55-'r— 97'• j o s X T F ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD I ect Recei ed By: (, Title: EHD 2 Rev 10/0B/ 7 /1 UST SERVICE REQUEST INSPECTION REPORT