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UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />?• —,E� •oma <br />SAN JOAQUIN COUNTY <br />Onsite Service Technician's Name: <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />" anufacturer Training: <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orp/ehd <br />:P <br />4�IF0 <br />❑ <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Facility Address: <br />Service Request #: <br />BIZ <br />Onsite Service Technician's Name: <br />ICC Service Technicia staller Exp. Date: <br />-l1 <br />" anufacturer Training: <br />SERVICE <br />qj Leak detector p► <br />KI ModeIN ` " LD <br />❑ <br />mechanical <br />❑ electronic Serial #: 09 (;1149_ <br />EHD Inspector.I <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <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 />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />EHD Inspector.I <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 />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 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 />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />THIS FACILITY IS SUBJECT TO REI NSP ION AT AhlTIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector.I <br />R tved By: <br />Title: <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />