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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.s*gov.onq/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />3-- <br />Service Request #: <br />Facility Address: <br />Manufacturer Training: <br />Onsite Service Technician's Name: icc S Ian/Installer Exp. Date: <br />Vk J11 - <br />SERVICE SERVICE <br />W Mom <br />Leak detector <br />0 mechanical Mod■el: E <br />1 <br />0 electronic Serial #: <br />0 line test programmed <br />■ <br />- <br />Leak detector <br />0 mechanical Model: <br />0 electronic Serial #: <br />0 line tesLpLogrammed <br />Leak detector <br />11 <br />0 mechanical Model: <br />0 electronic Serial <br />0 line test-•-roqrammed <br />sensor 001: <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />Q_NA 101 <br />esensor <br />Model: 40 <br />positive shutdown <br />0 fail safe Serial* 030 <br />0 NA <br />sensor <br />'itive shutdown Model: <br />0 pos <br />0 fail safe Serial #: <br />0 NA <br />Drop tube with mechanical overfill at 95% <br />op tube with mechanical overfill at 95% <br />1, Overfill prevention (see LG letter 150-1) <br />W Mom <br />NN UW2 &A <br />Received By: <br />EHID 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17/108 <br />_Spill bucket 0 minimum 5 gallon <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />■ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />0 1 hour hydrostatic 0 Incon TS -STS <br />i 0 Caldwell System 0 Other <br />Primary piping testing at: <br />_psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) 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 />installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel <br />Corrosion protection <br />Other: see below <br />NN UW2 &A <br />Received By: <br />EHID 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17/108 <br />