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AqulN �o. ,coG • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT H 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj oq v_org/ehd ��tFORa UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: Facility Address: 15 �N,lv� p .. "t �% Service Request #: O site Service Technician's Name: ICC Service Techni ian installer Exp. Date: Manufacturer Training: SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: THIS FACILITY IS SUBJECT •REINSP �`� ❑ 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 LIS 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 7 i ❑ Caldwell System ❑ Other THIS FACILITY IS SUBJECT •REINSP �`� Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping '12 i3, �ump(s) UST(s) 6strig f ��es components are next due by: i MAR& vk d upon Note: Please beaw re that 2° containm nt components are required to be teslr%b 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 EHD 23-04 ( UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10 iL ► .,. ...USE l'.; .' 7 i WA THIS FACILITY IS SUBJECT •REINSP �`� EHD Inspector: EHD 23-04 ( UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10