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Pqu(t�0 <br />.coG SAN JOAQUIN COUNTY <br />z -ter y ENVIRONMENTAL HEALTH DEPARTMENT <br />y• e <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Co, „n± Gl , 6 7G <br />to CDi <br />Facility Address: <br />Service Request #: <br />U10 j <br />gz 4(-0 <br />Onsite Service Technician's Namb: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ <br />- s i� <br />VPL q x- 6 <br />SERVICE <br />ho ue,C— c E2===6 d& G✓ $ U <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUB ECT TO REI NSPEC O T A Y TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />Rece' <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />El <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: 332175–oa ( — <br />❑ electronic Serial #• <br />❑ <br />❑ line test programmed <br />ensor 3 <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />NA 10 /1 <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 />ho ue,C— c E2===6 d& G✓ $ U <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUB ECT TO REI NSPEC O T A Y TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Rece' <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />t�-71?pill bucket ❑ minimum 5 gallon <br />El <br />El hour hydrostatic ❑ Incon TS -STS <br />❑ aldwell 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 />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />ho ue,C— c E2===6 d& G✓ $ U <br />THIS FACILITY IS SUB ECT TO REI NSPEC O T A Y TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />Rece' <br />Title: <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />