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ORaU I,N'•.0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Q: y .� <br />NAit 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si4ov.orq/ehd <br />C9C/FOR�`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />t <br />v <br />Inspection Date: <br />Foci ity Address: <br />❑ mechanical Model: <br />Service Request #: <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />M Lufacturer Training <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Ica,O <br />T/��l�:AW!C W <br />SERVICE <br />v <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />C1 A <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Ica,O <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />THIS FACILITY IS SUBJ <br />❑ fail safe Serial #: <br />TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ NA <br />Y, <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 />v <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />C1 A <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Ica,O <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />f <br />c -ria.. / �j � , a1 � � <br />Secondary containment testing for: <br />THIS FACILITY IS SUBJ <br />UDC(s) + Vf?— Piping <br />TIME AT EHD'S CURRENT HOURLY RATE. <br />Sump(s) UST(s) <br />Y, <br />Testing for the above components are next due by: <br />&%A <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />This USTfacilityis APPROVED to operate El This UST facility is NOT APPROVED to operate <br />C-++" r <G 1L' -T I 11 14 nd� tire. 1 �— ►�t� <br />V7:> C - I <br />v <br />L <br />JR <br />C1 A <br />Ica,O <br />r f <br />'%-�-` �`s�^ � <br />f <br />c -ria.. / �j � , a1 � � <br />.� cs�/ue,.. 3 r��ar�—• � ( 1 i <br />THIS FACILITY IS SUBJ <br />CT TO REINSPECTION AT ANY <br />TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins pec <br />R4 ived By: <br />Title: <br />EHD 23-04 / V UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />