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PqutN <br />o • c SAN JOAQUIN COUNTY <br />�+ ENVIRONMENTAL HEALTH DEPARTMENT <br />W. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />�'• P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fadlily Name: <br />Inspection Date: <br />Fac'/' <br />AUAq(. Jr <br />Servic Request#: <br />' <br />/' a <br />Onsite Servrce Tec Ician's a e: <br />1 <br />ICC Service Tec nicia stall r Exp. Date: <br />- 0' f � <br />Manufacturer Training: <br />-24 -IV <br />17 SERVICE <br />() i <br />Leak detector <br />❑ mechanical Model:L►©- <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />pCelectronic Serial #: I $7241 <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Title: <br />urw/f <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <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 />>6his UST facility is APPROVED to operate <br />SERVICE <br />() i <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 />EHD Inspecto ML2� <br />❑ Caldwell System ❑ Other <br />Title: <br />urw/f <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 />❑ This UST facility is NOT APPROVED to operate <br />� <br />O'l <br />() i <br />THIS FACT TY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspecto ML2� <br />IReceived By: J <br />L' &,,- 'L //0' 4/ + <br />Title: <br />urw/f <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />