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O.p4U!N• c <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />N. 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />C9�iFORN`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />ot v-%, rv-C <br />`7 7 c6 <br />Inspection Date: Z ', 3 ,-- -- <br />❑ <br />❑ mechanical Model: <br />— — o <br />Facility Address: <br />,65Ci5/ lJ� . i <br />a►��1.� �'fc .-� <br />Service Request #: �fip <br />c5V-0OS%r7 S'O <br />Onsite Service Technician's Name/ <br />Leak detector <br />ICC Servict Technician/Installer Exp. Date: <br />' <br />Manufacturer Training: <br />c� �• ,, _ <br />❑ electronic Serial #: <br />l C.K— 001 <br />le,*( V3 X-- 11 <br />SERVICE <br />�5 3 30�-- <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />1,_ e <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />� . <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 />❑ <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 />Overfill prevention (see LIS letter 150-1) <br />SERVICE <br />�5 3 30�-- <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />1,_ e <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />PECTION AT ANY TIME AT EHD'S CURRENT H RLY RATE. <br />❑ Caldwell System ❑ Other <br />� . <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />►� <br />,r <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />�5 3 30�-- <br />61� 4--, (wv <br />s <br />7 <br />Je <br />1,_ e <br />THIS FACILITY IS SUBJECT TO REIN <br />PECTION AT ANY TIME AT EHD'S CURRENT H RLY RATE. <br />EHD Inspect <br />� . <br />Title: ✓U <br />►� <br />,r <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />