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SAN JOAQUIN COUNTY <br />Q: Za ENVIRONMENTAL HEALTH DEPARTMENT <br />y? 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sagov.org/ehd <br />.. .t_.--,..�P <br />/FORM <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Ce)(O &yy! <br />Inspection Date: <br />b -e H <br />ee otJ <br />❑ <br />Facility Address: i - ` ". �}/� <br />lob D&O �N' � 11-5 <br />Seervviicce�R[eyquuest #: <br />�1��1 n Vq <br />nsite Service Technician's Name: <br />' � <br />ICC Service Technici n/Installer Exp. te: <br />Manufacturer Training: <br />as <br />❑ mechanical Model: <br />Ir, -14 - i -/ <br />SERVICE <br />Leak detector {� <br />❑ <br />Pmechanical Model: I -Y <br />❑ electronic Serial #: <br />❑ line test programmed <br />THIFAWY ISS CT TO REINSPECTION AT ANY TIME AT 'S CURRENT HOURLY RATE. <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIFAWY ISS CT TO REINSPECTION AT ANY TIME AT 'S CURRENT HOURLY RATE. <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 />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />THIFAWY ISS CT TO REINSPECTION AT ANY TIME AT 'S CURRENT HOURLY RATE. <br />EHD InspecL- <br />Received By: % <br />Title: <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />