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OAHU I IV C <br />SAN JOAQUIN COUNTY <br />2 _crr ENVIRONMENTAL HEALTH DEPARTMENT <br />••z <br />y. ?, 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*gov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />P <br />L 12, LAI Cb*�\ <br />Insption D te: <br />T/L1 <br />Facility Address: <br />1, �� <br />`) � <br />Serv%ceReque t <br />jZ <br />V <br />() ^ <br />tni (S I � � <br />/ 0,V U <br />Onsite Service Technician's Name: <br />Leak detector <br />ICC Selvice Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />L" <br />M <br />SERVICE <br />L 12, LAI Cb*�\ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />u M If <br />❑ electronic Serial #: <br />EH nspector: q <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 />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />XOther: <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 />L 12, LAI Cb*�\ <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />u M If <br />❑ Caldwell System ❑ Other <br />EH nspector: q <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 />XOther: <br />see below <br />p-,, (, <br />L 12, LAI Cb*�\ <br />� <br />r- 401211' Azalzhie-i, tva ^� o <br />W <br />u M If <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EH nspector: q <br />ceived By: <br />Title: <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />