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?'—+F�''•a SAN .IOAQUIN COUNTY <br />�i ENVIRONMENTAL HEALTH DEPARTMENT <br />` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />CA <br />Inspection Date: <br />c <br />Leak detector <br />1 � � J <br />Fac ity Address: y (( <br />Service Request #: <br />0W , V �_C <br />f ]11 <br />Onsite S Ice Technician's Name: <br />ICC Servi ' ian/lnstaller Exp. Date: <br />Manufacturer Training: <br />Cr',v <br />a(0 (oI�, <br />❑ minimum 5 gallon <br />SERVICE <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ Incon TS -STS <br />❑ line test programmed <br />❑ Caldwell System <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ minimum 5 gallon <br />❑ electronic Serial #: <br />❑ 1 hour hydrostatic <br />❑ line test programmed <br />Received By:Tuttle: <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Primary piping testing at: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />Piping <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />are next due <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 />NM This UST facility is NOT APPROVED to operate <br />1 +10 <br />SERVICE <br />1 <br />Spill bucket <br />❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic <br />❑ Incon TS -STS <br />q _ <br />❑ Caldwell System <br />❑ Other <br />Spill bucket <br />❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic <br />❑ Incon TS -STS <br />Received By:Tuttle: <br />❑ Caldwell System <br />❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) <br />Piping <br />Sump(s) <br />UST(s) <br />Testing for the above components <br />are next due <br />k-AAfCX&`�. <br />Wojj�fi <br />Note: Please be aware that 21 containm <br />t components are required to be tested upon <br />installation, 6 months after, and every 36 <br />onths thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />NM This UST facility is NOT APPROVED to operate <br />1 +10 <br />v Q e C' 19-C, <br />1 <br />, <br />i,' <br />j <br />q _ <br />—a=0tS (Xt olt <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD InFs�/ect`o/� (/► <br />Received By:Tuttle: <br />EHD 23-04 <br />Rev 4/30/12 <br />�!p-1"5 <br />f <br />UST SERVICE REQUEST INSPECTION REPORT <br />