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11Q <br />-- O <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.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />SERVICE <br />Inspection Date: <br />Leak detector <br />QQ <br />FaciltyyAddress: <br />Service Request #:9 <br />1ko `—") j� r <br />ISW�st <br />Onsite Service Technician's Name: <br />ICC Service Tech nf ian/Installer Exp. Date: <br />Manufacturer Training: pPW — --3 -it —2-:a <br />C.a7 kms_ <br />-1 0-210 1 C <br />- <br />�VR-610-19 ',,/AL -r - '-3-1-4- <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 />,RPM <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 950/o <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 />,RPM <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />iris <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 />Other: see below <br />This UST facility is NOT APPROVED to operate <br />r <br />• r <br />�� -Me WE <br />•. -s _ . <br />r <br />,RPM <br />•► t",/• i • • , L <br />• •- <br />MIUVFJF� RIF t <br />iris <br />EHD 23-04 <br />Rev 4/30/12 <br />109� <br />UST SERVICE REQUEST INSPECTION REPORT <br />