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OAqu!N C <br />?•''��''•a� SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />y` 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />A�iFpYit� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility tpm : <br />Inspection Date: <br />❑ <br />CA4VV44-11^ <br />❑ electronic Serial #: <br />;111111111 jiijl�III1111111111 III <br />THIS FACILITY IS SUBJECT TO REINSPECTIO <br />Facility Ad ess: <br />aa� <br />S rpm--�v <br />Service Request #: <br />�3z <br />Onsite Seeervvicechnician's me: <br />kyhe <br />❑ mechanical Model: <br />ICC Service Technicianlinstalller Exp. D �tje:: <br />M n/uffa'ctturer Whining: <br />❑ <br />❑ line test programmed <br />Leak detector <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />;111111111 jiijl�III1111111111 III <br />THIS FACILITY IS SUBJECT TO REINSPECTIO <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 />❑ 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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />;111111111 jiijl�III1111111111 III <br />THIS FACILITY IS SUBJECT TO REINSPECTIO <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 />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />EHD 23-04 s' UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />�,r, � <br />Ali` <br />EM <br />;111111111 jiijl�III1111111111 III <br />THIS FACILITY IS SUBJECT TO REINSPECTIO <br />FAW"�;.. <br />EHD 23-04 s' UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />