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ta,u!.N. <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />y ` 600 East Main Street, Stockton, CA 95202-3029 <br />;P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />9��POR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fa IIIme: <br />Inspection Date: AZ- <br />1`2,6rr <br />I6L <br />W <br />Facility Address: <br />.l, PS N LN' L49)'�� � <br />Service Request #: <br />'U-00(67-70 <br />O site Service Tec ician' N P: <br />ICC Service Technic(ian�llnsfaller Exp. Date: <br />facturer Tr <br />v <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />a. r _ Tel/,/1l <br />Leak detector n <br />❑ mechanical Model: ?LS) Ut` <br />❑ <br />electronic Serial #: <br />'4T�L 4 <br />❑ line test programmed <br />Leak detector SO I tn1 <br />❑ <br />❑ mechanical Model: <br />[Kelectronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ mechanical Model: —1-- ��-- <br />Relectronic Serial #: <br />❑ line test programmed <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <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. r _ Tel/,/1l <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />'4T�L 4 <br />❑ Caldwell System ❑ Other <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 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />a. r _ Tel/,/1l <br />Ma:G <br />VIME AT EHD'S CURRENT HOURLY RATE. <br />'4T�L 4 <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />