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oQRu.°�•• c <br />? ' o SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />N= ` 600 East Main Street, Stockton, CA 95202-3029 <br />�•.: b iP <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />p�®ORS® ®g �+ p ® �+®p ®� �s ® �® �®® <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Spill bucket minimum 5 gallon <br />Inspection Date: <br />❑ <br />❑ mechanical Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: <br />Spill bucket ❑ minimum 5 gallon <br />Fa ility dr s: <br />N�� Tam <br />UA , T—rRA <br />Service Re ue t <br />X #: <br />crfib <br />❑ <br />-'?5;00 <br />Onsiffi P4rvice Technician's Name: <br />Primary piping testing at: <br />cc Service Tech ician/Install r Exp Date: <br />Manufacturer Training:± <br />❑ line test programmed <br />minutes <br />id 647, <br />_,0 &2_a ov� <br />� <br />""t <br />r <br />bk <br />- <br />SERVICE <br />Spill bucket minimum 5 gallon <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: <br />Spill bucket ❑ minimum 5 gallon <br />❑ line test programmed <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Primary piping testing at: <br />❑ electronic Serial #: <br />psi <br />❑ line test programmed <br />minutes <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />UDC(s) Piping <br />❑ fail safe Serial #: <br />Sump(s) UST(s) <br />❑ NA <br />Testing for the above components are next due by: <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Cold start of monitoring panel <br />❑ fail safe Serial #: <br />Corrosion protection <br />❑ NA <br />Other: see below <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 />This UST facility is APPROVED to operate <br />i® Q— A 't �e <br />❑ This UST facility is NOT APPROVED to operate <br />t L <br />F <br />ryr <br />THIS FACILITY IS SUBJECT TO REINSPE11#11001ATIA TIME AT EHD'S CURRENT HOURLY RATE. <br />EH ctor: Rece d Title: <br />6 L� I <br />EHD 23-04 UST SERVIC REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />Spill bucket minimum 5 gallon <br />our 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 />LEI <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />t L <br />F <br />ryr <br />THIS FACILITY IS SUBJECT TO REINSPE11#11001ATIA TIME AT EHD'S CURRENT HOURLY RATE. <br />EH ctor: Rece d Title: <br />6 L� I <br />EHD 23-04 UST SERVIC REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />