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O.1,9L IN••.0 <br />SAN JOAQUIN COUNTY <br />T ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />Cq F O'R�`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspecti n Da e: <br />U C �v�-s-L, <br />It Z � b <br />Facilitt Address: <br />C) l F IG r �� w IS/t&&tel <br />Servicd Request #: <br />/ZOO S 8 0-2,$ <br />Onsite Service Technician's Name: <br />l( P Uw j <br />IC Service Technic n/Inst Iler Exp. Date: <br />�S I /11 <br />Manufacturer Training: <br />e /\ M/� <br />6 it /! <br />❑ <br />SERVICE <br />v-/ ' ne S <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />Ce, wv1.6 <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />EHD Inspector: <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 />❑ 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 />v-/ ' ne S <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Ce, wv1.6 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />I ,Nem, v <br />❑ Caldwell System ❑ Other <br />EHD Inspector: <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 />Ncondary containment testing for: 3 to f,7 <br />'I <br />UDC(s) Piping <br />Sump(s) UST(s) <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 />rl I <br />v-/ ' ne S <br />'vL Q r -Z �J Dom. 1-1 ( e <br />Ce, wv1.6 <br />Vbr\/' <br />e I I vh 1- <br />I ,Nem, v <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />Received By: <br />n <br />Title: <br />S <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />