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0.?4� I N••.c <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />c9�iFoa�''vP <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 />Facilit Name: <br />% - - <br />Date: <br />L.,I�-% <br />G LInspection <br />�T�-F� 7-7 -? <br />- c.--> 151 <br />Facility Address: <br />Rec ed By: <br />Service Request #: <br />❑ <br />�'11n i a <br />Onsite Service Technician's Nam : <br />ICC Wrvice Technician/Installer Exp.Date: <br />Manufacturer Training: // <br />❑ <br />❑ line test programmed <br />1,.Ae ._ ?/ 2,4 J q <br />tr— I hS 4.- I/e, <br />SERVICE <br />% - - <br />A110-1 Leak detector G� <br />Model: <br />❑ <br />mechanical <br />�C <br />❑ electronic Serial #:L�j Z_( 4 Cl <br />Rec ed By: <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 />❑ <br />❑ NA <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 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />.)5 <br />SERVICE <br />% - - <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Rec ed By: <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 />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 21 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 />►� LArii,, Ivy l o,=. <br />% - - <br />L 64 h -f a 14 j4was 4 W -j w," 4-t. -c e•. � ����fGs <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspec <br />Rec ed By: <br />Title: <br />I <br />EHD 23-04 <br />Rev 11/17808 <br />0- <br />I -2- <br />UST SERVICE REQUEST INSPECTION REPORT <br />