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AQU I,N <br />�o. .co <br />OENVIRONMENTAL <br />SAN JOAQUIN COUNTY <br />HEALTH DEPARTMEN <br />40 <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />_ Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />C4�/FOR�`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facilit Name: <br />,A <br />Leak detector <br />Ins a tion Date: <br />LIT� 15 <br />Facility Address: <br />( � - it�� d (A <br />�J"� <br />9.0 <br />Service Request #: <br />Onsite Service ec nician's Na e: <br />FT- PA 11�ew'I <br />ICC Servile Technician/ staller Exp. Date: <br />-R - l 7 0-�i <br />Manu cturer Training: <br />� �7 <-- <br />SERVICE <br />Owl w5k 51 1 <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 />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 />❑ 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 />Owl w5k 51 1 <br />A Spill bucket ❑ minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System )W 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 21 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 />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 EQUEST INSPECTION REPO <br />Owl w5k 51 1 <br />lop aL It <br />THIS FJCI,LITY IS SUBJF_CT TO REINSPE9TION AT ANY TIME Pq .. <br />EHD Inspector: <br />IMM"W2.10NOW—I'l <br />VIA <br />t. '1W P-- <br />NOW <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE EQUEST INSPECTION REPO <br />