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°A0.uty 'O SAN JOAQUIN COUNTY <br />a '?a ENVIRONMENTAL HEALTH DEPARTMENT <br />N < <br />Y. 600 East Main Street, Stockton, CA 95202-3029 <br />' Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />9�jFOR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facili Name: <br />Inspection Date: — i30 <br />fro- <br />->>- <br />5-11-/0 <br />❑ mechanical Model: <br />THIVACILITY IS SUBJECT TO REINS'..rte ��r.CURRENT HOURLY RATE. <br />Facility <br />Facility Address: <br />Service Request #: <br />Onsite Service Technician's Wine: <br />WC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ <br />❑ mechanical Model: <br />z <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIVACILITY IS SUBJECT TO REINS'..rte ��r.CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />_ sensor <br />❑ <br />❑ positive shutdown Model: <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 />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIVACILITY IS SUBJECT TO REINS'..rte ��r.CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <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 />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />�L Sump(s) UST(s) <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 />r �t <br />THIVACILITY IS SUBJECT TO REINS'..rte ��r.CURRENT HOURLY RATE. <br />EHD Inspyeeil <br />�// z <br />EHD 23-04 v UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11 /17//08 <br />