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at ,o <br />_;• ,�„—..c SAN JOAQUIN COUNTY 0 <br />z ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: 209 468-3420 Fax: 209 468-3433 Web: www.s'aov.org/ehd <br />�/FORH <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Facility Address:��,,” " , <br />�3a3 N ��uV1 �a " 4,W0 <br />Service Request #: <br />5vDemog <br />Onsite Service Technician's Name: <br />lGC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />�wpk Nly- <br />� k1to <br />I VM I i vts -71 12 <br />SERVICE <br />�. l .� tLLS �. L i <br />Leak detector P <br />mechanical Model: VrA LD 2X0 <br />❑ <br />Oqo <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Madel: <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 />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 />�. l .� tLLS �. L i <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 />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 />LIDC(s) Piping <br />Sump(s) LIST(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 />❑ <br />Other: see below <br />L .� [1 l�I !r u/ <br />�. l .� tLLS �. L i <br />tom' I'I ' 1./..I� ) /%, a/ % [l <br />4MWA21M..1I{ .AI OUR• � <br />W/ W M IAl /i/IIA <br />EHD 23-04 U / <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />