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AQU 1 /y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ¢• _ `fit N 1868 East Hazelton Avenue, Stockton, CA 95205-6232 q ;p Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: I�A'rm s Inspection Date: 3/1�- Facility Address: ^^ ,, t' A Service Request #: /:7 p� S C) 0 o I teService Technician's Name: Onsiitp 10C Service Te hnician/Installer Exp. Date: Manufacturer Training: ❑ line test programmed ❑ SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: Title: ❑ 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 Title: Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) Oi:d 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 In! .'-i KzSS a r TH ACILITY IS SUBJECT TO REINSPECTION AT A TIME AT EHD'S CURRENT HOURLY RATE. EH=specI Rec ' ed Title: 32 Rev l V f C/ Rev 4//3 2 u UST SERVICE REQUEST INSPECTION REPORT