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i PgUt,N. <br />SAN JOAOUIN 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.orc;/ehd <br />,_ciFoRN/ <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facilit Name: <br />Inspection Date: <br />c% -o <br />1 i —Q—'2� ` 9 <br />Facility Address: <br />Service Request #: <br />❑ electronic Serial #: <br />Onsite Service Technician's Name:C <br />ICervice Technician/lnsta 2LEtp. Date: <br />Manufacturer Training: <br />��n <br />i - i <br />Olv D C <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 />EHD I ctor: � p � � !� <br />�lJ�-�- l:(J . <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 950/0 <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 />EHD I ctor: � p � � !� <br />�lJ�-�- l:(J . <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 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"it <br />Wi <br />This UST facility is NOT APPROVED to opera e , II I <br />1 Y 1l T <br />6A SA C <br />V \ eld i 4 _ <br />l <br />THIS FACILITY IS SUBJECT TO REINSPECTION NY TIME AT S CURRENT HOURLY RATE. <br />EHD I ctor: � p � � !� <br />�lJ�-�- l:(J . <br />Receiv Title: <br />fG✓ <br />EHD 23-04 V <br />Rev 23-04 /// <br />I:Si <br />10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />