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Pqu t N. <br />SAN JOAQUIN COUNTY <br />-rte ENVIRONMENTAL HEALTH DEPARTMENT <br />Q: a <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sJgov.org/ehd <br />�4CFFOR�`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facili Name: Inspection <br />Ml 0i eve;, <br />Date: <br />10-13-1 <br />Facility A �res� , <br />�`� " i�i , � <br />Service Request #: <br />�(�6C6 7 <br />Onsite Service Tqnician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />SERVICE <br />IN, N <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />IrV <br />❑ electronic Serial #: <br />1 <br />�� / iy r' ..V�' �1' 1. <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />s � �■Ir,c/� <br />rr <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />I iNsensor <br />Model:64- <br />❑ positivd shutdown <br />0 fail safe rrII Xal #: 'T',.--7' 1- <br />❑ <br />❑ NA kt- al -7-A 40 ML <br />81 dN V sens <br />R ? 4;9t 467 <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: G,C <br />❑ <br />❑ NA <br />qL aNn 44- sensor <br />' <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: �S t ob <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 />IN, N <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />IrV <br />❑ Caldwell System ❑ Other <br />1 <br />�� / iy r' ..V�' �1' 1. <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />• • •WA <br />❑ Caldwell System ❑ Other <br />s � �■Ir,c/� <br />rr <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: 160 L INS. <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 21 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 />FM <br />IN, N <br />iU 4�_ <br />'171 <br />Ei <br />IrV <br />�.�/..f.1►� <br />1 <br />�� / iy r' ..V�' �1' 1. <br />• • •WA <br />��� , <br />s � �■Ir,c/� <br />rr <br />.A <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />