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SAN JOAQUIN COUNTY <br />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 />C9�iFORa`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />C-ZA + r o _ <br />InspectionDate: <br />) � 1 %C) <br />Facility Address: <br />❑ mechanical Model: <br />Servicd Request #: <br />g/? -3 <br />Onsite Service Technician's <br />me: <br />CC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />13 r (� <br />❑ <br />c' 0-,1 6 a <br />PA11.4, x-- <br />v <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />-EP <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />,— C,111-0 ,15 <br />❑ electronic Serial #: <br />l��'�I <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />!L <br />❑ electronic Serial #: <br />❑ line test programmed <br />D'S CURRENT HOURLY RATE. <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />Title: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <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 />OSpill bucket ❑ minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System SZOther ti� <br />-EP <br />h CAA lit <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />,— C,111-0 ,15 <br />❑ Caldwell System ❑ Other <br />l��'�I <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />!L <br />Primary piping testing at: <br />psi <br />D'S CURRENT HOURLY RATE. <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Title: <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 />Other: see below <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />-EP <br />P2122 <br />h0 ?" <br />n <br />�c.C�Y <br />,— C,111-0 ,15 <br />pp <br />Gt rX I.q'f� • <br />l��'�I <br />!L <br />9 <br />THIS FACILITY IS SUBJECT TO REINS ECTION AT ANY TIME ATE <br />D'S CURRENT HOURLY RATE. <br />EHD Inspect <br />Received B <br />Title: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />