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- Of RECEIVED <br />�o__E.e�ti SAN JOAQUIN COUNTY <br />tr <br />!j Z-11 ENVIRONMENTAL HEALTH DEPARTMENT AR Q 8 017 <br />;. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicgov.orq/ehfj <br />ENVIRONMENTAL HEALTH <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPEMMRIUNWT <br />Facility Name: <br />Inspection Date: <br />Facility' Adckess: <br />❑ mechanical Model: <br />Service Request <br />Onsite Service Technician's Name: ICG Service TechnicianAnstaller.Exp. Date: <br />C� 4 blou <br />Manufacturer Training: <br />y <br />❑ <br />Leak detector <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />C.p <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT�ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Title <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />C7 <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 />D NA <br />❑ <br />Drop tube with mechanical overfill at 95% <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 />�:. k <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon T5 -STS <br />C.p <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />} <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 />Title <br />minutes <br />Secondary. containment testing for: <br />f 1 r-) UDC(s) Piping <br />a Sump(s) UST(s) <br />C7 <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. thereaRer. <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 />I <br />a YC t ' ft ti , -'"Ft <br />' <br />C.p <br />. , 'D f' w 4L -' I Q . t +�4 <br />F k - 'fib .- { :.imri 8.r - '�{$� jai <br />} <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT�ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />Received By > <br />Title <br />EHD 23-04 <br />Rev 4130112 <br />UST SERVICE REQUEST INSPECTION REPORT <br />