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SAN JOAQUIN COUNT -0 <br />Y <br />- ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fac' ' Name: <br />I Lo L <br />Inspection Date: <br />_1 <br />Facility Address: <br />Service Request #: <br />1 ( <br />Poo -+k4 <br />Onsite Servi Technician's Name: <br />ICC Service Tech ician/In Ilex Ex te: <br />Manufacturer Training: <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />SERVICE _ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ electronic Serial #: <br />❑ Caldwell System ❑ Other <br />line test programmed <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: <br />Primary piping testing at: <br />❑ line test programmed <br />psi <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Secondary containment testing for: <br />❑ fail safe Serial #: <br />UDC(s) Piping <br />❑ NA <br />Sump(s) UST(s) <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Note: Please be aware that 2° containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ fail safe Serial #: <br />Cold start of monitoring panel <br />❑ NA <br />Corrosion protection <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 />SERVICE _ <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ 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 2° 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 />i <br />Other: see below <br />This UST facility is APPROVED to operate El This UST facility is NOT APPROVED to operate <br />lilll i • -"� ; _il _ i iart • it i ±'�I !' <br />md 011 • � rt. •. Q � k i �` r• 41"VW . ' 0 <br />0 <br />EHD 23-04v V ` UST SERVICE�REQUEST INSPECTION REPORT <br />Rev 4130/12 <br />