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ull <br />SAN JOAQUIN COUNTY <br />X ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />?- %-- <br />Facility Address: Service Request #: <br />79oco c-Ze Dor.:,xc� 5 ADO 5;2�33/95% -L3/3 _s5b <br />Onsite Service Technician's Name: ICC_Service Technician/Installer n/Installer Exp. Date: Manufacturer Training: r <br />I <br />SERVICE <br />SERVICE <br />Spill bucket El minimum 5 gallon <br />Leak detector <br />0 1 hour hydrostatic 0 Incon TS -STS <br />THI§LfACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT E'S CURRENT HOURLY RATE. <br />0 mechanical <br />Model: \)a- qrq v --f <br />-2-1757!.cit <br />— Spill bucket 0 minimum 5 gallon <br />IRmlectronic <br />Serial #: <br />0 line test programmed <br />Spill bucket 0 minimum 5 gallon <br />c Leak detector <br />El <br />Model: U/4,6�vtE <br />mechanical <br />Primary piping testing at: <br />)a:electronic <br />Serial #: <br />0 line test programmed <br />Secondary containment testing for: <br />Leak detector <br />UDC(s) Piping <br />El <br />0 mechanical <br />Model: <br />Testing for the above components are next due by: <br />0 electronic <br />Serial #: <br />El <br />El line test programmed <br />El <br />Corrosion protection <br />--A-? A, I I sensor <br />C14 -A N k- I ,. , t -x-& + <br />0 positive shutdown <br />Model: <br />Afail safe <br />Serial #: 2,4.j:2- 1� <br />A <br />cfl -ftw— sensor <br />;R positive shutdown <br />Model: 323 <br />fail safe <br />Serial #: 2,g2.!%:j I <br />El NA <br />sensor <br />El <br />0 positive shutdown <br />Model: <br />0 fail safe <br />Serial <br />0 NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />Fj <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />I <br />SERVICE <br />Spill bucket El minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />THI§LfACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT E'S CURRENT HOURLY RATE. <br />El Caldwell System 0 Other <br />Receive <br />— Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />F-1 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System El Other <br />Primary piping testing at: <br />El <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) LIST(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 />El <br />Cold start of monitoring panel <br />El <br />Corrosion protection <br />El <br />Other: see below <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />THI§LfACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT E'S CURRENT HOURLY RATE. <br />EHD Inspe r <br />Receive <br />Title: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />