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�E� •o SAN JOAQUIN COUNTY <br />GZ-t ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.o[g/ehd <br />'nib `P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />SERVICE <br />ti 4j V <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />'-tH16 FACILITY IS SUBJECT TO REINSPECTION AT ANY fNE AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />Receive y:t. ITitle: <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 />ti 4j V <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />'-tH16 FACILITY IS SUBJECT TO REINSPECTION AT ANY fNE AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Receive y:t. ITitle: <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 20 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />`P <br />Cold start of monitoring panel — %Gt G <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />— <br />ti 4j V <br />SA -47i pw <br />,�1 � dna_ t/�-�c�+„t ,�-c�v� — �Z�. •f � c-,rv� <br />-� rr <br />'-tH16 FACILITY IS SUBJECT TO REINSPECTION AT ANY fNE AT EHD'S CURRENT HOURLY RATE. <br />EHD inspector: <br />Receive y:t. ITitle: <br />u <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17!/08 <br />