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rL <br />m <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s4gov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: i <br />fi <br />Inspection Date: <br />MAPLA Ip ) <br />Facility Address: <br />Service Request #: <br />Onsite Service Technician's Name: <br />IAN 4 i,7�5 <br />ICC Service Technician/Installer Exp. Date: <br />IC�o(I I In p z v1 r <br />Manufacturer Trai in <br />1 .� V. �{ <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <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 />❑ <br />❑ NA <br />LON <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 />❑ This UST facility is APPROVED to operate <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 />LON <br />Other: see below <br />This UST facility is NOT APPROVED to operate <br />s fs . wPt-FR AtOR M Cr haf <br />9Qr • ` �' <br />"' '-ae ro P42MO,4Cd UDCG and CIGSOCActMID <br />jPQMC s1 ► . „ I • C) 1)SPI <br />Z r <br />ae . / . ✓w f / )' of <br />i1 r/ <br />I THIS FACILITY IS SUBJECT TO REINSPECTION ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector:,� Received By: _ Title: <br />EHD 23-04 Rev. 04/19/12 UST SERVICE REQUEST INSPECTION REPORT <br />