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OA'gUt/y C � • SAN JOAQUIN COUNTY w; { ENVIRONMENTAL HEALTH DEPARTMENT :. 600 East Main Street, Stockton, CA 95202-3029 Y. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd •9C%FOiRta UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facili Name: Inspecti n Date: 1.� � 1� Facility Addr ss: Service Req st M On ite Servide Technician's a ICC Service Technician/Ins Iter Exp. Date: Manuf ct rer Training: ❑ Leak detector ❑ SERVICE Leak detector O&W ❑ echanical Model: VH( THIS FACILITY IS SUBJECT TO REINSPECTION AATANY TIME AT EHD'S CURRENT HOURLY RATE. electronic Serial #: Received By: '\ Q �� ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS THIS FACILITY IS SUBJECT TO REINSPECTION AATANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other Received By: '\ Q �� Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 20 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below EHD 2 4 Rev 11/17//08 UST SERVICE REQUEST INSPECTION REPORT THIS FACILITY IS SUBJECT TO REINSPECTION AATANY TIME AT EHD'S CURRENT HOURLY RATE. Inspector: Received By: '\ Q �� Title: EHD 2 4 Rev 11/17//08 UST SERVICE REQUEST INSPECTION REPORT