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0.qulN <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />W: < <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orq/ehd <br />9�%FORS <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />F cility N e: <br />Inspection Date: <br />NA <br />wj-A2( <br />�3-17- 1-0 <br />Facility dress: <br />Z -Z -Z,+ <br />Service Request #: <br />tuNDIN(J <br />Onsite Service Technician's Name: <br />ICC ervic Technician/Installer Ex Date: <br />Manufacturer Training: <br />❑ <br />Leak detector <br />❑ <br />SERVICE <br />Leak detector 1 / <br />❑ <br />�@ mechanical Model: tsZG� <br />❑ electronic Serial #: <br />y�. (-e-1L Sr S 1 <br />❑ line test programmed d <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Titl . <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 />W <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />y�. (-e-1L Sr S 1 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />EHD In ct . <br />❑ Caldwell System ❑ Other <br />Titl . <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 21 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 />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 Z) (�r <br />Ii YP_Nts <br />y�. (-e-1L Sr S 1 <br />CLAAV <br />HIS FACILITY IS SUBJEICT TO REINS ECTION AT ANY TIME AT EHD'S CURREN URLY RATE. <br />EHD In ct . <br />Received By: <br />Sud TSF( <br />Titl . <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 Z) (�r <br />