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oPQ`'''IN• c SAN JOAQUIN COUNTY cr -+ ENVIRONMENTAL HEALTH DEPARTMENT W: > 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.segov.org/ehd �IFpR� UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: ror.► Inspection Date: I - I S - ,_ Facility T � q AMM1,6, � L, 9q�7Cb vi #:t 10 PA Onsite Service Techni ' n's Nam ❑ line test programmed ICC Service Techn iarUl staller Exp. Date: _I, o1�- Manufacturer Training: SERVICE Leak detector O ❑ mechanical Model: Serial V1 zo ❑ )!electronic #: ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) ❑ This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi EHD Inspector: minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12 ' %' % • • • • EHD Inspector: IN Title: EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12