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AQuIN <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or /q ehd <br />�gGiFOR�`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />ci(ity Name,:, � --\,-� <br />I`�uqY10 <br />Inspection Date: <br />�_ 01 <br />Leak detector <br />❑ <br />Facility Addre : <br />l5 `�N1 <br />Service Request #: <br />nsite Servi Techn clan's Name: <br />VhI <br />IC Service Te nician/Installer Exp. Date: <br />-2S �2 2a-��i <br />M nufacturer Training: <br />I <br />.q1 <br />AA <br />Leak detector <br />❑ <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />�'u41J fa / <br />❑ electronic Serial #: <br />NRILL <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />1111�l. 2�,!► +al.�� ■i-� <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />Nt <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />�J�11I1 • <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />-. WE.�►� <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 />�'u41J fa / <br />❑ Caldwell System ❑ Other <br />NRILL <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 />1111�l. 2�,!► +al.�� ■i-� <br />minutes <br />, �`►ll� 1�. �r �.ih 0IQ= <br />Secondary containment testing for: <br />UDC(s)ia3� ho Piping <br />Nt <br />1 Lf S Sumps) U�ST(s) <br />rtdsting or the a o omponents are ne dLite <br />I` <br />�I t % ^ d p?I �. <br />�J�11I1 • <br />Note: Please As aware that 2° containment components are reci a to be tested upon <br />installation, 6 months after, and every 36 months thereafter. •J <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 />EHD 23-04 <br />Rev 10/06/10 <br />C UST SERVfE REQUEST INSPECTION REPORT <br />�'u41J fa / <br />NRILL <br />Ii r <br />1111�l. 2�,!► +al.�� ■i-� <br />l� <br />, �`►ll� 1�. �r �.ih 0IQ= <br />iM <br />I` <br />�J�11I1 • <br />1� f • I� u(� , <br />a���-- <br />-. WE.�►� <br />Amldvw"AA�� <br />EHD 23-04 <br />Rev 10/06/10 <br />C UST SERVfE REQUEST INSPECTION REPORT <br />