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O.PQuIN C <br />?''E''' P� SAN JOAQUIN COUNTY <br />_ ENVIRONMENTAL HEALTH DEPARTMENT <br />y_� 600 East Main Street, Stockton, CA 95202-3029 . <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />iiR�� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: ` <br />�Ib� <br />Inspection Date: <br />E - ,pl <br />Facility Address: <br />23� t <br />'N , �', <br />Service R quest #: <br />ite Service Tec nician's Name: <br />NAWA-v\VQt7, <br />ICC Service TechnicianLinstaller Exp. Date: <br />Itz 1 6-29,1-7> <br />Manufacturer Training: <br />/kW"V4' jo n -i <br />❑ line test programmed <br />❑ <br />Leak detector <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />1 <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />A <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 />❑ <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 />1 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />A <br />psi <br />E,•U 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 />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />►r� <br />l�l►�`��►I�ll�.�1�11 " I�II�.�.!►1-101, ,a.�� b 11►&Lei <br />1 <br />THIS FACILITY IS SUBJECT TO REINSPECT EAT EHD'S CURRENT HOURLY <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />