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oPau'N c SAN JOAQUIN COUNTY <br />e. 'yam ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.org/ehd <br />9��FORN <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />❑ <br />❑ mechanical Model: <br />Facility Address: <br />co <br />Service Request #: <br />❑ <br />Leak detector <br />❑ <br />Onsite Service Technician's Name: <br />&c> <br />ICC Se ice Technician/Installer Exp. Date: <br />Manuf turej Trainipg: <br />r l ✓� <br />❑ line test programmed <br />r.Recei <br />Leak detector <br />- <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />co <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />&c> <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />r.Recei <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />5,positive shutdown Model: V %, 7Z ``` ^ <br />jR'fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail 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 LIS letter 150-1) <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />co <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />&c> <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />r.Recei <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 />AT <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />EHD 23-04 7'', VV <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />41 <br />G�. <br />�� 1 • c vc.- — -� _. --At za, b -e- . <br />co <br />c c c,55 <br />&c> <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />In <br />EHD Inspe <br />r.Recei <br />By: <br />Titles <br />EHD 23-04 7'', VV <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />