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Pqu I,N <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />a• � <br />y.600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />4�%FORa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />rA <br />Inspection Date: <br />-7— C <br />mechanical Model: �Ci Lp Ddb <br />2-10110 <br />Facility Address: <br />- - ff <br />Service Request #: <br />13 ►vla,w, S r <br />M <br />❑ <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />l IS1� <br />Manufacturer Training: <br />04/1 <br />❑ line test programmed <br />z g g u 1 I <br />P �S 3 9- DPS <br />SERVICE <br />rA <br />Leak detector <br />❑ <br />mechanical Model: �Ci Lp Ddb <br />THIS F`ACILITY IS SUBJECT TO %' <br />❑ electronic Serial #: j&) 2j4k <br />- - ff <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 />l <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />-)_(kz '3 / r / // <br />SERVICE <br />rA <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS F`ACILITY IS SUBJECT TO %' <br />❑ Caldwell System ❑ Other <br />- - ff <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 />l <br />50 psi <br />60 minutes <br />Secondary containment testing for: SPST 60 <br />Ay <br />UDC(s) $7 iping <br />Sump(s) UST(s) <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 />❑ <br />Other: see below <br />Ownns <br />rA <br />THIS F`ACILITY IS SUBJECT TO %' <br />EHD Inspector! <br />- - ff <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />