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oAQ�.�N• c <br />�:•E' .oG SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.segov.org/ehd <br />��/FORS <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facili Name: <br />Leak detector <br />Inspection Date: <br />Un <br />❑ electronic Serial #: <br />-L- <br />Facility <br />cility Addre//ss�: <br />❑ <br />Leak detector <br />Se ce R quest#: <br />10 s_ <br />G ; <br />[ <br />�C iG�u—� <br />� 6 _( 52>. <br />Onsite Service Technician's Name: <br />[cc Service Technician/Installer _Ex�Date: <br />Manufacturer Training: <br />i c e. -u43 <br />-t4A LA -f— <br />—• i <br />❑ fail safe Serial #: <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 />❑ 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 />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 />Title: <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Testing for the above components are next due by: <br />r-\/ I A <br />Note: Please be a are that 2° containment components are required to be tested upon <br />installation, 6 months after, and every 36 moriths 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 />C'a't" <br />THI ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />E H D InsZtvRe <br />d By: <br />Title: <br />EHD 23J(4----/��,�` C-- Q- �S/, Gil.. UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 77�� yJ <br />bc,c- s @ s3<-- v <br />