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oPauly <br />?•�' •a SAN JOAQUIN COUNTY <br />Q: ENVIRONMENTAL HEALTH DEPARTMENT <br />r� <br />Y. 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or /q ehd <br />A�FORa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: --� <br />Inspection Date: <br />Fa ility Address: % <br />�G.H� .1� �-r Gi c�L Com• <br />Service Request #: <br />--� (�V ��r� <br />Onsite Service Technician's Name: ICC S rvice Thnician/Installer Exp. Date: <br />Manufacturer Training: <br />SERVICE <br />1r 1.20 - r Rr.5k� <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 />�-, <br />❑ fail safe Serial #: <br />0�4— <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />to <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 />SE IkilICE <br />1r 1.20 - r Rr.5k� <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 />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />�-, <br />UDC(s) Piping <br />0�4— <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />to <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />�� <br />1r 1.20 - r Rr.5k� <br />F' <br />�-, <br />�-� <br />0�4— <br />L -d/ Inied Gt1 <br />T SF#CILITYIS <br />SUBJECT TO REINSPECTION AT <br />ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />7 Ins ori j <br />Rec ' d By: <br />Titig: <br />Cc <br />EH&23-10W <br />Rev 10/0 10 <br />►mss <br />V UST SERVICE REQUEST INSPECTION REPORT <br />