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a°PauIN o0 <br />", a SAN JOAQUIN COUNTY <br />c. ENVIRONMENTAL HEALTH DEPARTMENT <br />w• X <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />tc'• - eP <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />94�Fo'FR <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />F c' ity Nam'�, �k Inspection D te: <br />WVA I <br />-7N W Nik" - <br />rA-- I q <br />Facility Address: ® Service Request #: <br />c <br />nsite Servi a Technician's Name: ICC Service Te niciaWinstaller Exp. Date: Manufacturer Trai ing: <br />- �t f`T'vs- <br />VThis UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />Leak detector <br />mechanical Model: L� <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ electronic Serial #: I�6512 <br />❑ line test programmed <br />❑ <br />BrI Leak detector V <br />mechanical Model_ _ <br />❑ electronic Serial #: .. <br />❑ <br />❑ line test programmed <br />rtak BIW. <br />❑ positive shutdown Mod el: <br />❑ fail safe Se 'al #: d <br />El NA 1- <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />VThis UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <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 />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />VThis UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />