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SAN JOAQUIN COUNTY 10 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />X <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Facility Address: Service Request <br /><-66(;1 c a rc (scIS99--) -3 <br />Onsite Service Technician's Name: ICC Service Technician/installer Exp. Date: Manufacturer Training: )e — Il I'SA <br />9 <br />SERVICE <br />Leak detector <br />El <br />El mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />• electronic Serial #: <br />Received zfl <br />0 line test programmed <br />El <br />Leak detector <br />El <br />0 mechanical Model: <br />• electronic Serial #: <br />0 <br />0 line test programmed <br />Leak detector <br />El <br />0 mechanical Model: <br />El <br />0 electronic Serial M <br />El line test programmed <br />4 Kn- 6- - sensor <br />0 positive shutdown Model: 01-Z q -0f <br />,.Wail safe Serial#: 4F 4-6111f <br />❑ <br />0 NA <br />sensor <br />El <br />0 positive shutdown Model: <br />El <br />0 fail safe Serial M <br />El <br />DNA <br />sensor <br />El <br />0 positive shutdown Model: <br />0 fail safe Serial M <br />0 NA <br />❑- <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />— Spill bucket El minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />El Caldwell System 0 Other <br />Received zfl <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System 0 Other <br />Primary piping testing at: <br />El <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) LIST(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 />M <br />Cold start of monitoring panel <br />El <br />Corrosion protection <br />El <br />Other: see below <br />7 EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />P <br />EHD Inspe &F. ) <br />Received zfl <br />Till <br />7 EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />