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HA APQ� F h ?•' �'�•'• SAN .IOAQUIN .COUNTY I cNVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si4ov.orQ/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: Vq 1aq�j1 VIP ❑ Facilityyclresj Servrvicce� quest #: Onsite Service Technicians Name: ICC Setvice Tec ician/Installer Exp. Date: Manufacturer Training: SSac Leak detector 4 - Iq - O SERVICE Leak detector ❑ ❑ mechanical Model: i�1LV.lS�IL' ❑ electronic Serial #: ! ❑ 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 i�1LV.lS�IL' ❑ Caldwell System ❑ Other ! Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes D� S condary containment testin for: 2 t'S 1 UDC(s) _' C(5 Piping Sump(s) UST(s) Testing for the above components are next due by: V"3 r-Aea t,,lpvb� ne AA l.0QU 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 111P -ok— EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12 i�1LV.lS�IL' Ill t , ! Low 111P -ok— EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12