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O.PQ'U I,N,••.0 <br />SAN JOAQUIN COUNTY <br />Q'�..I,,����'' ENVIRONMENTAL HEALTH DEPARTMENT <br />y . '. 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s6gov.org/ehd <br />�/PORE <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Q,fde- <br />p�j <br />Facility Address: <br />Service Request #: <br />SILOO 5 616 <br />Onsite Service Technician's Namd <br />ICC Se ice Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ <br />Leak detector <br />k4l"I z/3 <br />SERVICE <br />� ��' I f�"-r-- <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />r <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 />,9 <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 />SERVICE <br />� ��' I f�"-r-- <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />r <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />EHD Inspector: <br />/�AAdf �4y.,Z— <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 20 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection qc-1 5q,� <br />,9 <br />Other: see below <br />V/7 �.r.�..� •-o b� G.��iI_ Ug5 ►L..S TSI �GeX 5 i r�ti <br />� ��' I f�"-r-- <br />/�TJi � C`i G . �v�, /clw �O �%i �N ka-- <br />� I r� ✓ v.w� a <br />r <br />HIS FACILITY ISS BJECT TO REINSPECTION AT ANY tIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />/�AAdf �4y.,Z— <br />Received By:Title: <br />�zl� <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />