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°�auty 'O SAN JOAQUIN COUNTY <br />a a ENVIRONMENTAL HEALTH DEPARTMENT <br />y 600 East Main Street, Stockton, CA 95202-3029 <br />' Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />9CjFo'Rli. <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />8c_ <br />Inspectio Date: <br />©o �1 <br />Facility <br />5� � VTIrQ/ <br />Service _e <br />6101 <br />Onsite Service Technician's Name: <br />I;, a I,� <br />ICC Servic Te nician/Installer Exp. Date: <br />c I <br />Manufact rer Tra ing: <br />`� 11 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />/.l1. l <br />❑ electronic Serial #: <br />I•1 / I itti�ia <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS ATBJ <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 />❑ 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 />/.l1. l <br />❑ Caldwell System ❑ Other <br />I•1 / I itti�ia <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />I � I <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS ATBJ <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 2° 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 <br />❑ <br />Other: see below <br />V -� <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />p IR <br />ITFA )i A _6 ZTE, ��.'..�r� • p4. <br />/.l1. l <br />I•1 / I itti�ia <br />Ma <br />I,� <br />I � I <br />THIS FACILITY IS ATBJ <br />I <br />ION AT ANY TIME AT <br />V -� <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />