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o.P4u l!Y • <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Y. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />............ <br />P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Leak detector <br />1;- l O- o <br />Facility Address:: <br />Service Request #: <br />('` <br />b 1' �'Ct �— 1)�bfp <br />Received By: <br />Onsite Service Technician's Name: <br />ICC Service Techniciantinstaller Exp. Date: <br />Manufacturer Training: <br />%''1�.,.�. ` `'(� �o�._ <br />k — V �I- f b <br />�. yds �•— Tia-,.. = <br />SERVICE <br />Leak detector <br />El❑ <br />mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />Received By: <br />❑ line test programmed <br />❑ <br />Leak detector <br />El❑ <br />mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />E]❑ <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 />El❑ <br />positive shutdown Model: <br />❑ <br />❑ fall safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />E]❑ <br />positive shutdown Model: <br />❑ fall 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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Received By: <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 />ones testing for: <br />�S <br />, It��`�—�`1L.1�� UDC(s) Piping <br />:314-ntaiDC(s) <br />Sump(s) UST(s) <br />Testing for the above components are next due by: <br />Note: Please be aware that 20 containment components are required to be tested upon <br />installation, 6 nwnths after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />e� U o 55 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />Received By: <br />Title: <br />.G. <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />