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op4� I M• •.c <br />?•' -..E� •9 SAN .JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Q• a <br />N. { <br />'.�. 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.org/ehd <br />9�%FORCE <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Faci' Name: <br />InspectiorlDate: <br />-16 <br />Leak detector <br />❑ <br />F cility Address: <br />GA14-0�- /jj, IAI <br />Service Re #: <br />'S <br />Onsite Service Technician's Name: <br />ICC Se ice Technician/l staller Exp. Date: <br />Manufacturer Tr tm g: <br />fn-�(e-ttw I Z <br />❑ <br />Leak detector <br />❑ <br />SERVICE <br />-A�-, <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS 61LITY IS SUBJECT TO REI- •IME <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 />9,positive hutdown Model: _.L-1Vl,CI) <br />fail safe Serial #: <br />❑ <br />❑ NA - yak ccc_ 4U - <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 />-A�-, <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 />THIS 61LITY IS SUBJECT TO REI- •IME <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />MPyVary piping testing at: 6,165A <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <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 />"!AVW,7 <br />=is' <br />-A�-, <br />6T'SiffiNur. <br />! y� <br />THIS 61LITY IS SUBJECT TO REI- •IME <br />AT.CURRENT HOURLT <br />LHD 23-04 <br />Rev 111171!08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />