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SAN .JOAQUIN COUNTY <br />co <br />Q' -+ 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.org/ehd <br />'9CjFp'�t� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />7- EL611 q <br />21zz1/0 <br />Facility Address: <br />Service Request #: <br />13,11 nl VV &iv <br />SP -OO 59 -71 Z <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />8rw-Irnjqg 1 <br />524-11$a2- U17 - 5/ n <br />A 3// 31 t! o I i( <br />SERVICE <br />cl l S,7T swwt t�-- e wA f'- <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />l a S o -7 S <br />❑ electronic Serial #: <br />I <br />UA <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Receiv y: <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 />❑ 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 />cl l S,7T swwt t�-- e wA f'- <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />l a S o -7 S <br />❑ Caldwell System ❑ Other <br />I <br />UA <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />F IL IS JEC O EINS E IO AT ANY YIME ATE 'S CURRENT'HOURLI RATE. <br />❑ Caldwell System ❑ Other <br />Receiv y: <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 21 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />allfillill', 1 <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />cl l S,7T swwt t�-- e wA f'- <br />C rL15 tn�L� w� <br />l a S o -7 S <br />'11A <br />I <br />UA <br />Cb( <br />S CA'�w, <br />F IL IS JEC O EINS E IO AT ANY YIME ATE 'S CURRENT'HOURLI RATE. <br />EHD Inspector: ( <br />VIA <br />Receiv y: <br />Titl <br />allfillill', 1 <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />