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o?a�l.N• c <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />y_ 600 East Main Street, Stockton, CA 95202-3029 <br />_ ;P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or /q ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility N'aAme: <br />—T` <br />SERVICE <br />D �p <br />CX �Vv <br />Inspectti`on Date: <br />(� 47—il, ' <br />Facility Address: <br />❑ electronic Serial #:1, Il <br />100 <br />Service Request #: <br />On ite Service Technician's N e: <br />ICC Service Technician/Installer Exp. Date: <br />x b`-)o`l f z <br />Manufacturer Training: <br />z <br />vm I P�5-7b x OW (2- <br />SERVICE <br />l eak detector <br />.P -mechanical Model: i%Ki Lq uD 2D <br />El <br />❑ electronic Serial #:1, Il <br />100 <br />li M1 <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />fa" This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />El <br />1 hour hydrostatic ❑ Incon TS -STS <br />li M1 <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 a <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />LVIA <br />li M1 <br />Ztmmmi <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD -,� or.: <br />_.��. <br />ReceiyPOPBY: <br />zz �,,- <br />EHD 23-04 a <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />