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oPaut� •'c SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />N' [ <br />600 East Main Street, Stockton, CA 95202-3029 <br />_ Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s4gov.org/ehd <br />............. <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />FacilityAddress: <br />S <br />Service Request #: <br />s ►,��� G <br />�S`�i �s <br />Onsite Service Technician's Na e: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Tr ining: <br />oto <br />❑ <br />Leak detector <br />❑ <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 />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <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 />❑ 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:� Ufa <br />_i—' psi — '57) `iJ�d�ok.l <br />60 minutes <br />Secondary containment testing for: <br />fd::pQ60,.f.�.UDC(s) Piping <br />Sump(s) _ UST(s) <br />u tic iN •k.s h�A 1 �QQ, �-• <br />Testing for the above components arbinext 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 />I— THIS FACILITY IS SUBJECT TO REINSPECT( �Y TlWA( WD'S CURRENT HOURLY RATE. <br />EHD Inspectpt�) / —`J 1 Rg y I I Title: <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />