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o.P4�ly., SAN JOAQUIN COUNTY <br />r. �~ ENVIRONMENTAL HEALTH DEPARTMENT <br />'. 600 East Main Street, Stockton, CA 95202-3029 <br />�dCIFORNhP <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.siaov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />jiy j) ht. a- <br />Inspection Date: <br />Z � S �— <br />13❑ <br />mechanical Model: <br />Facility I <br />y t o t. Sc c.Aymoi . Z 51 <br />Service #: <br />/Address: <br />_ Leak detector <br />JRequest <br />Onsite Service Technician's Name: <br />Re ce' <br />ICC Service Te chniciaNlnstaller Exp. Date: <br />Manufacturer Training: <br />❑ line test programmed <br />Leak detector <br />❑ <br />u <br />SERVICE <br />jiy j) ht. a- <br />Leak detector <br />13❑ <br />mechanical Model: <br />❑ electronic Serial #: <br />y t o t. Sc c.Aymoi . Z 51 <br />❑ line test programmed <br />❑ <br />_ Leak detector <br />11❑ <br />mechanical Model: <br />Re ce' <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fall safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fall safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <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 DZ -5 <br />jiy j) ht. a- <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />y t o t. Sc c.Aymoi . Z 51 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />AT ANY TIME AT EHD'S CURRENT HOURLY RAT . <br />❑ Caldwell System ❑ Other <br />Re ce' <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />nnary piping testing at: <br />g' <br />th psi <br />l02 minutes <br />Secondary taiC(stesting for: <br />6 4 o DC(s) o11'a5e..Piping <br />` , D) <br />Sump(s) UST(s) <br />Testing for the above components are next due by: <br />2- 6 - /0 uleb.-I p,r= a17) <br />Note: Please be aware that 20 containment components are required to be tested unon <br />Installation, 6 months after, and awry 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />�e. +- <br />jiy j) ht. a- <br />y t o t. Sc c.Aymoi . Z 51 <br />THIS FACILITY IS UBJECT TO REINSPECTIPIN <br />AT ANY TIME AT EHD'S CURRENT HOURLY RAT . <br />EHD Inspect <br />Re ce' <br />Title: <br />5/9 <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17/108 <br />