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oA4u�N c <br />SAN JOAOUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />c.P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />-9�jFOR�` <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />r co <br />Inspection Date: <br />�q <br />Facility Address: <br />Servide equest #: <br />Onsite Service Technician's Name: ICC $ervic echnician/installer p. Date: <br />Manufacturer Training: <br />❑ electronic Serial #: <br />a <br />As <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />a <br />❑ line test programmed <br />CAW� <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />•r �� �m s -i b '0'f rkLz>. <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />Receiv <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <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 />qffs--,Spill bucket ❑ minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />' <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />a <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />CAW� <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />•r �� �m s -i b '0'f rkLz>. <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 />Receiv <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 a, <br />1 <br />This UST facility is NOT APPROVED to operate <br />l e1 <br />M) <br />EHD 23-04 ( ^ UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />a <br />`u <br />CAW� <br />•r �� �m s -i b '0'f rkLz>. <br />ori cam - <br />It S h S'�_ 0 60 JL <br />THIS FACILITY IS SUBJECT TO REINSPECTIOV <br />AT AW TIMq AT EHD'S IbURRENTIHOURLY RATE. <br />EHD InsplaCtor: <br />Receiv <br />Title: II <br />l e1 <br />M) <br />EHD 23-04 ( ^ UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />