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Iz� �f••.o� $AN JOAQUIN COUNTY <br />w � ENVIRONMENTAL HEALTH DEPARTMENT <br />'+ 600 East Main Street, Stockton, CA 95202-3029 <br />q Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siciov.org/ehd <br />CIFORti <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name:Inspection <br />Ma ' djr, GL-° _ <br />Date: <br />Il (12(0 9 <br />Facility Address: <br />23q s rb r > �I vE %afro /� <br />Service Request#: �. <br />s 2 Bail -6 S <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />SERVICE <br />Leak detector <br />El <br />mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINS P NY,TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />El <br />e <br />❑ line test programmed <br />❑ <br />Leak detector <br />El❑ <br />mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />El <br />mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />El <br />❑ line test programmed <br />sensor <br />E]❑ <br />positive shutdown Model: <br />❑ fall safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />El❑ <br />positive shutdown Model: <br />❑ <br />❑ fall safe Serial #: <br />❑ NA <br />sensor <br />E]❑ <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINS P NY,TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />e <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 2° 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 />s � <br />Let- U 0 - 2'S IF <br />THIS FACILITY IS SUBJECT TO REINS P NY,TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: A rM <br />,vo( <br />e <br />Title: <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />