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oPQU.I.N• c <br />is <br />2: �-cFi—; •Gy <br />SAN JOAQUIN COUNTY <br />c- <br />�.._ <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />9�/FOFLT� <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.smqov.orq/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: ti <br />WV <br />Insp tion Dat : I <br />Facility Address: <br />%� (� <br />L,6 <br />Se ice Request # <br />�/v esK�l <br />❑ electronic Serial #: <br />1'A , V^\ ls� <br />❑ line test programmed <br />O ite Service Tec ni n's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Ma ufacturer Training: <br />t u+� <br />12.S 2 2 `L <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />..�► SIL. 4 • N t /,1,"11, ' 1 { 4 1 �' <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />• - . I�tt <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 />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 />..�► SIL. 4 • N t /,1,"11, ' 1 { 4 1 �' <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />�� • li. <br />❑ Caldwell System ❑ Other <br />• - . I�tt <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 21 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 />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />am <br />..�► SIL. 4 • N t /,1,"11, ' 1 { 4 1 �' <br />�� • li. <br />THIS FACILITY IA SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY <br />• - . I�tt <br />Re - : . <br />EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />