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oq'•q� l � c <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />�d��FORa`p <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Ul/ a7 ! oo �� <br />Inspectio D e: <br />v/��//10 <br />Facility Address: <br />.3 ,-;7.�. l,�z46r) dD ,2d . <br />Service Request #: <br />8uw W /I .� �G>tSJ�iISS <br />Onsite Servi a Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />11:5 <br />Leak detector <br />vkm 2l <br />SERVICE <br />NZ <br />Leak detector <br />mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />I Mill 11111111 11 rpw <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 />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 />'RM <br />ON ii �� Av_ <br />I Mill 11111111 11 rpw <br />i / l i� ��' �—/7 1 �' <br />_/. <br />1 /L " <br />,117 <br />EHD 23-04 "� ®,�py���//IG�CJ/ �` //�N ev "/ / //� �fCX•i i� ��Cl�� <br />Rev 11/17//08 //%�� "' — �rs� Q �� SERVICE REQUEST INSPECTION REPORT <br />wy�hin / 6ys�r�f'�° <br />