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I.N. 'o¢. 4uF c9 41 oo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT N: t 600 East Main Street, Stockton, CA 95202-3029 ;P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd '4�fFOR� UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT FacilityName* �1 4 I l Inspection Date: ca -ill - b Facility Addr s: ❑ mechanical Model: Service Request #: 11 Onsite Service Technician's Name: ICC Service Tec hn ianllnstaller Exp. Date: Manufacturer Training: 7S� R,11-1-11 Leak detector ❑ SERVICE I l Leak detector ❑ ❑ mechanical Model: W= ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed • Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA sensor 0-r4f;,64) - ❑ dhutdown Model: !!�t ❑ ;ositive fail safe Serial #: -759'6P:;' ❑ ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE I l Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS W= ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS • ❑ Caldwell System ❑ Other WN Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below . �' �� I l '.'.V W= i 1 , - • +� / AN �. • !�4;5:4,7r�44[&7414 , pis WN EHD 23-04 Rev 11/17//08 UST SERVICE REQUEST INSPECTION REPORT