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pP••q'V(N p <br />SAN JOAQUIN COUNTY <br />rs' <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />< <br />600 East Main Street, Stockton, CA 95202-3029 <br />=e: (209) 468-3420 Fax: (209) 468-3433 Web: www.siclov.orq/ehd/FOUNDERGROUND E TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />0;e�4f) -16 <br />�J,Imkfaur <br />Inspection Date: <br />7113101 <br />Facility Address: <br />'7 DO ?, ' <br />v'd IN" <br />Service Request #: <br />99-OD 5b z--9 <br />Onsite Service Technician's Name: <br />WfA Wi1W&s <br />EHD Insl!l <br />ICC Service Technician/Installer Exp. Date: <br />q` ID <br />Manufacturer Training: <br />VI' A33-71?3 % <br />SERVICE <br />�J,Imkfaur <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />EHD Insl!l <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 <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />�J,Imkfaur <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />EHD Insl!l <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 />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 />�J,Imkfaur <br />i <br />I/1 Ute- M <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Insl!l <br />Received By: kA <br />I Title: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />