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SAN JOAQUIN COUNTY <br />OENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*-qov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Facility Address- Service Request #: <br />ly?aA4-1 9T e44!X-"— �40 66 /go(. <br />Onifife -Service Technician's Name: ICCfService Technician/installer Exp. Date: Manufacturer Training: <br />G�ZS"Zq-Zg 6/702, 11t< AW.AzS00t <br />SERVICE <br />Leak detector <br />❑ El mechanical Model: <br />0 electronic Serial #: <br />El line test proorammed <br />El Caldwell System El Other <br />Leak detector <br />El <br />0 mechanical Model: <br />El 1 hour hydrostatic 0 Incon TS -STS <br />El electronic Serial #: <br />0 Caldwell System El Other <br />0 line test programmed <br />Spill bucket 0 minimum 5 gallon <br />Leak detector <br />❑ <br />El mechanical Model: <br />El Caldwell System 0 Other <br />El electronic Serial #: <br />Primary piping testing at: <br />El line test programmed <br />psi <br />sensor <br />El <br />0 positive shutdown Model: <br />Secondary containment testing for: <br />El fail safe Serial <br />UDC(s) Piping <br />• NA <br />Sump(s) ILISTI <br />sensor <br />El <br />0 positive shutdown Model: <br />Note: Please be aware that 20 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />• fail safe Serial #: <br />Cold start of monitoring panel <br />0 NA <br />Corrosion protection <br />sensor <br />El <br />El positive shutdown Model: <br />0 fail safe Serial <br />0 NA <br />0 <br />Drop tube with mechanical overfill at 95% <br />F-1 <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />I SERVICE <br />e9 I <br />iIMW <br />Spill bucket El minimum 5 gallon <br />El <br />El 1 hour hydrostatic El Incon TS -STS <br />El Caldwell System El Other <br />EHID Inspector: <br />Spill bucket El minimum 5 gallon <br />El <br />El 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic El 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) ILISTI <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 20 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 />El <br />Corrosion protection <br />El <br />Other: see below <br />e9 I <br />iIMW <br />F"A <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHID Inspector: <br />F�aceived By* <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />