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ug I <br />SAN JOAQUIN COUNTY <br />err. Z 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 />& I i <br />WCL-terloc L. L4i l Azocq- <br />Facility Address: V Service Request #: <br />...-N " <br />5 1 T t <br />b -A <br />Onsite Service Technician'Name: ICC Service Technician/installer Exp. Date: Manufacturer Training: <br />9r"('-� molAo'lard 52956200 -UT I A (61A <br />SERVICE <br />Leak detector <br />El 0 mechanical Model: <br />0 electronic Serial #: <br />El line test programmed <br />Leak detector <br />❑ <br />0 mechanical Model: <br />❑ <br />0 electronic Serial #: <br />0 line test programmed <br />Leak detector <br />'El <br />0 mechanical Model: <br />0 electronic Serial #: <br />0 line test programmed <br />F1 <br />sensor <br />❑ <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />DNA <br />sensor <br />El <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />0 NA <br />1pi;d <br />Y's <br />sensor <br />El <br />0 positive shutdown Model: <br />F-1 <br />0 fail safe Serial #: <br />El NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />lig I M&MIN <br />SERVICE <br />Spill bucket El minimum 5 gallon <br />El <br />0 1 hour hydrostatic El Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket El minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <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 />Primary piping testing at: <br />F1 <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />El <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 />1pi;d <br />Y's <br />— -If <br />Cold start of monitoring paneli,,n(M <br />0 <br />Corrosion protection <br />F-1 <br />Other: see below <br />1 1111111�pI!111111 1� <br />0 A S'NaM =5 <br />rVIA rz JR1 <br />ON r <br />• W-11 h'! Will III I jj I 1T4• <br />1•:7 <br />EHD 23-04 kl� UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />