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rlf---k <br />SAN JOAQUIN COUNTY <br />Fa ENVIRONMENTAL HEALTH DEPARTMENT <br />.•', 600 East Main Street, Stockton, CA 95202-3029 <br />.r Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s ov.or lehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAMA SERVICE REQUEST INSPECTION REPORT <br />co <br />Facility Address: <br />?�-Q t+0 <br />Onsite Service Tech <br />11 <br />F-1 <br />� 4N.siitj v,, * 40 3 <br />Dan I eL sf <br />clan's Name: <br />h N <br />�-s- n i3�nA.Y� AW.l1C� <br />'v 0j L <br />Service Technician/installer Exp. Date <br />° �^ <br />SERVICE <br />7Ir9[05AMItin—FM iLM <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />electronic Serial #: <br />/. lief t <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test ro rammed <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 />El 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°10 <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />Inspection Date: <br />(0 --2-0 — 24 [o <br />Service Request #: <br />Manufacturer Training: <br />SERVICE <br />7Ir9[05AMItin—FM iLM <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />/. lief t <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 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 />Other: see below <br />ll cl r 111 1 Irii74A,,,i CII IA'k, , iA !.%-"An._rr, 1h i t .`I . t .I .-I, ._ <br />A <br />0 <br />u <br />EHO 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/171!08 <br />7Ir9[05AMItin—FM iLM <br />1121 ME <br />N <br />-M <br />1 I Itr�n 11t a 11 a l?lt ►i +! j �N ►�_ ,� *•lt r, a ._. I <br />11� <br />/. lief t <br />i.". _ �1i !, t i, �JtI ri j '. ! &! <br />d - <br />A <br />0 <br />u <br />EHO 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/171!08 <br />