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o➢'•au l�••.c <br />SAN JOAQUIN COUNTY <br />— Z ENVIRONMENTAL HEALTH DEPARTMENT <br />y. 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si.qov.org/ehd <br />'9CjF�R� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />F Iity,.Name: <br />Inspection Date: <br />❑ <br />❑ mechanical Model: <br />Fa0ltY Address: <br />❑ line test programmed <br />Service Request #: <br />Leak detector <br />71-7 <br />❑ mechanical Model: <br />V f f Gt -s f 4j(-'1 U �-j r. (VA ICU kSk Jct? 19` wj CL jdftSSS t <br />nsi Serv'�re Technician's Name: <br />17 U i/YU i^ �Nh— <br />CC Service Technician/Iinstaller Exp. Date: <br />j 2`� 0&10 -- (-f 1 <br />Manufacturer Training: <br />M,-- <br />001 /o hi <br />'(Z"' <br />SERVICE <br />I r `&'Leak detector ,v �, Nu <br />❑ <br />❑ mechanical Model: <br />electronic Serial #: 1� 5 <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />V f f Gt -s f 4j(-'1 U �-j r. (VA ICU kSk Jct? 19` wj CL jdftSSS t <br />❑ electronic Serial #: <br />[:1 <br />❑ line test programmed <br />e Ived <br />k4— <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />E] <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 />❑ <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 />Overfill prevention (see LIS letter 150-1) <br />LIl J=Mii��'iN13i <br />SERVICE <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 />v 'D) P,ft�" ('1�{\e <br />❑ Caldwell System ❑ Other <br />V f f Gt -s f 4j(-'1 U �-j r. (VA ICU kSk Jct? 19` wj CL jdftSSS t <br />Spill bucket ❑ minimum 5 gallon <br />[:1 <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />e Ived <br />k4— <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />E] <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />I.42h Sump(s) 11 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 />instillation, 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./, < )cd <br />EHD 23-04 <br />Rev 11/17//08 <br />`71 f* St 2 ' est /'` s <br />UST SERVICE REQUEST INSPECTION REPORT <br />U iN <br />Vl /U I lu ",a, <br />IJ it�S Ua-C Ste. <br />v 'D) P,ft�" ('1�{\e <br />Z° -f!�fi Qn5 a� fV <br />V f f Gt -s f 4j(-'1 U �-j r. (VA ICU kSk Jct? 19` wj CL jdftSSS t <br />THIS FACILITY IS SUBJECT TO REINSPECTI N AT MY TIFE AT EHD'S CURRENT HOURLY R <br />EHD In — <br />e Ived <br />k4— <br />Title: <br />L./, < )cd <br />EHD 23-04 <br />Rev 11/17//08 <br />`71 f* St 2 ' est /'` s <br />UST SERVICE REQUEST INSPECTION REPORT <br />