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PqulN <br />SAN .10AQUIN COUNTY <br />2 —err y 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 />9�1FOR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name:n/ <br />/ oo'Q MeF►— <br />Inspection Date: <br />':�-1 2Z— c> <br />Facility Address: <br />Service Request #: <br />--23 2-0 E'L -Po -5+- <br />�IZop Seo 9 h <br />Onsite Service TechniciaaName: <br />ICC Service Technicianlinstaller Exp. Date: <br />Manufacturer Training: ' I <br />J <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION Y TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />Receiv <br />O's 0'-- <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 ' '�j 2 <br />Model: J` <br />❑ <br />El positive shutdown 7D3 <br />❑ <br />ail 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 />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION Y TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Receiv <br />O's 0'-- <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />aw � �-- 1 � � t �r-►--s . l a <br />THIS FACILITY IS SUBJECT TO REINSPECTION Y TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins r: <br />Receiv <br />O's 0'-- <br />Title:" <br />EHD 23-04 <br />UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />