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ohF�lH. c <br />a•'�E't'••p SAN JOAQUIN COUNTY it <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />P. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sioov.orc/ehd <br />�IFO'R� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name:�I{-- <br />}�- \ <br />Leak detector <br />El❑ <br />In ('fcti Date: <br />❑ <br />❑ electronic Serial #: <br />IV <br />❑ line test programmed <br />❑ Caldwell System <br />Facility Address: <br />+323 <br />9 kky <br />V <br />Service Request #: <br />S neol <br />Onsite Service Technician' N <br />e:ICC <br />S rvice T hnician/Installer Exp. Date: <br />Manufacturer Training: <br />kul <br />_ <br />❑ mechanical Model: <br />$01 <br />�,wlcT <br />❑ <br />SERVICE <br />SERVICE <br />Leak detector <br />El❑ <br />_ <br />mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ Incon TS -STS <br />❑ line test programmed <br />❑ Caldwell System <br />Leak detector <br />El❑ <br />mechanical Model: <br />❑ minimum 5 gallon <br />❑ electronic Serial #: <br />❑ 1 hour hydrostatic <br />❑ line test programmed <br />Leak detector <br />❑ <br />_ <br />❑ mechanical Model: <br />Spill bucket <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />❑ Incon TS -STS <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fall safe Serial #: <br />a� <br />❑ NA <br />psi <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fall safe Serial #: <br />Sec dry containment testi ,9g fp <br />❑ NA <br />_ UDC(s) <br />sensor <br />❑ <br />_ <br />❑ positive shutdown Model: <br />UST(s) <br />❑ fail safe Serial #: <br />Testing for the above components are next due by: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />installation, 6 months after, and every 36 months thereafter. <br />Drop tube with mechanical overfill at 95% <br />V[:Ove;rfill <br />prevention (see LG letter 150-1) <br />aw-RWINNINERY MOM, Wo <br />SERVICE <br />R."03W <br />Spill bucket <br />❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic <br />❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY <br />❑ Caldwell System <br />❑ Other <br />Spill bucket <br />❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic <br />❑ Incon TS -STS <br />❑ Caldwell System <br />❑ Other <br />Spill bucket <br />❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic <br />❑ Incon TS -STS <br />❑ Caldwell System <br />❑ Other <br />rary piping testing at: <br />!0P,! <br />a� <br />psi <br />50 minutes <br />Sec dry containment testi ,9g fp <br />_ UDC(s) <br />t6�G1 Piping <br />Sump(s) <br />UST(s) <br />Testing for the above components are next due by: <br />Note. Please be aware that P wntainment components are required to" tested uwn <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 />aw-RWINNINERY MOM, Wo <br />i ,Lu 'I1"i .. �"I'MEtV <br />R."03W <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY <br />e .o �,�_� <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />