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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />y. ` 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />�q � % F O•R�`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facilit , ame: <br />Inspection Date: <br />Leak detector <br />❑ <br />Facility Address: <br />bub <br />Service Request #: <br />5,2D05 X673 <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date:anufacturer <br />MTraining: <br />❑ <br />Leak detector <br />❑ <br />SERVICE <br />1 IVB Y'rn✓:l� ,fh <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACI ITY IS SUBJECT TO REI NSPECTIO T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />LRr2ed <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />ElOverfill <br />prevention (see LG letter 150-1) <br />SERVICE <br />1 IVB Y'rn✓:l� ,fh <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACI ITY IS SUBJECT TO REI NSPECTIO T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />LRr2ed <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 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 />❑ <br />Other: see below <br />' ,j �J- C � <br />1 IVB Y'rn✓:l� ,fh <br />q 1 <br />THIS FACI ITY IS SUBJECT TO REI NSPECTIO T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspe or• <br />LRr2ed <br />Titla-- <br />EHD 23-04 <br />Rev 11/17808 <br />UST SERVICE REQUEST INSPECTION REPORT <br />