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og'qu ly c ?• �E�' P SAN JOAQUIN COUNTY . { ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/e UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facili�lt:i%ii'� Inspection Date: ,,� Facility Address: (sol / CA 13X Service Request #: 607-76 Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: 361 � 2012 Manufa turer Training: &P �� !� SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: Q ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE C� Mill bucket k minimum 5 gallon R9 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other V1\ pill bucket t9minimum 5 gallon ® 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: LIDC(s) Piping Sump(s) UST(s) Q Testing for the above components are next due by: Note: Please be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection Other: see below DIRK, flll ' l / Rec EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 11/17//08