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SAN JOAQUIN COUNTY <br />NVIRONMENTAL HEALTH DEPARTMEN# <br />N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sugov.org/ehd <br />C9�iFORa`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />. / C A <br />Inspection Date: <br />(n,I-1,6 c� <br />o <br />❑ <br />Facility Adddrress:f� „ <br />Wik <br />Service Request #: <br />--*,- o 0 -� k <br />Onsite Service Technician's Name: <br />M ("('5p <br />ICC Service Tec ician/Installer Exp. Date: <br />/VA <br />Manufacturer. Training: <br />0 - <br />�. , , <br />Leak detector <br />❑ <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 />EHD Inspector <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <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 />❑ 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 />�. A.- <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />EHD Inspector <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 />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 />This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 4/30/12 <br />�/ UST SERVICE REQUEST INSPECTION REPORT <br />C-) �-L <br />ca-- u ) — <br />ti <br />�. A.- <br />e <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME <br />EHD'S CURRENT HOURLY RATE. <br />EHD Inspector <br />ReceivedMB�/ / <br />Title: j <br />Iref <br />EHD 23-04 <br />Rev 4/30/12 <br />�/ UST SERVICE REQUEST INSPECTION REPORT <br />