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400 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjqcv.ora/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date:, <br />T1 <br />W 0 01 ocll� II 0 <br />Facility Address: Service Request #: <br />1), tiammp-9 Lone, Stplcr-fvll SP 0071,--j C1 l <br />Onsite Service Technician's Name: ICC Service Tech nician/Instal ler Exp. Date; Manufacturer Training: <br />Ark W Ll M39 <br />SERVICE <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />Leak detector <br />F7 <br />0 mechanical Model: <br />El electronic Serial #: <br />D line test programmed <br />El <br />Leak detector <br />El <br />0 mechanical Model: <br />El electronic Serial #: <br />❑ <br />El line test programmed <br />sensor <br />E positive shutdown Model: <br />El fail safe Serial #: <br />El NA <br />sensor <br />[:1 positive shutdown Model: <br />El fail safe Serial #: <br />El NA <br />El <br />sensor <br />❑ <br />El positive shutdown Model: <br />El <br />0 fail safe Serial #: <br />11 NA <br />El <br />— Drop tube with mechanical overfill at 95% <br />0 <br />— Drop tube with mechanical overfill at 95% <br />E] <br />Overfill prevention (see LG letter 150-1) <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />— Spill bucket El minimum 5 gallon <br />El <br />El 1 hour hydrostatic El lnccn TS -STS <br />El Caldwell System El Other <br />— Spill bucket El minimum 5 gallon <br />El <br />El 1 hour hydrostatic [I Incon TS -STS <br />El Caldwell System El Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secoj@ry containment to ' g for: <br />7 — <br />UDC(s) Piping <br />Sump( s, UST(s) <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 />El <br />I Cold start of monitoring panel <br />El <br />Corrosion protection <br />El <br />Other: see below <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />