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?•''--+E"�''•o 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.sjgov.org/ehd <br />�qG%F+ORa`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />GiL L,C- 7o <br />S`,2A�:)-o <br />Facility Address: <br />3,;vz w <br />Service Request #: <br />�i 5-7 <br />�,.�.�� �� <br />11 <br />Onsite Service Technician's Name: <br />ICrService Technician/Installer Exp. Date: <br />Manufacturer Training: <br />V k ISI <br />,mobe.,,_ IIA440 <br />-7 t ° <br />R ved <br />L <br />SERVICE <br />a i a. <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />- 4toq - <br />❑ electronic Serial #: <br />11 <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />R ved <br />L <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />..- sensor <br />Model: VA 79"�3;1Z) q6 <br />positive shutdown <br />bafail safe Serial #: -753 7,112 <br />❑ <br />t <br />❑ NA <br />sensor 4F Pte, <br />❑ Model: <br />❑ <br />positive shutdown <br />❑ fail safe Serial #: <br />rEl <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 i a. <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />- 4toq - <br />❑ Caldwell System ❑ Other <br />11 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />HD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />R ved <br />L <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 />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 20 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 />rEl <br />Corrosion protection <br />Other: see below <br />h f .�,•- oma. '�' <br />a i a. <br />•-� (.., <br />- 4toq - <br />11 <br />T ACILITY ISS BJEC O REINS TI AT NY TIME A <br />HD'S CURRENT HOURLY RATE. <br />EHD I pecto <br />R ved <br />L <br />Title: <br />EHD 23-04/y UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11 /17//08 <br />