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O�GgU l,M• C <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />yi 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.org/ehd <br />A�/FORa <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Dater <br />^� <br />6 <br />�J <br />Facility Address: I <br />Service Request #: <br />s-) s ca„� C1 � 6 8 �,, 4 <br />�rLo<75 -, - � <br />Onsite Service Technician's Namb: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ line test programmed <br />SERVICE <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ <br />❑ mechanical <br />Model: <br />Spill bucket ❑ minimum 5 gallon <br />❑ electronic <br />Serial #: <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ <br />❑ mechanical <br />Model: <br />❑ electronic <br />Serial #: <br />psi <br />❑ line test programmed <br />minutes <br />Leak detector <br />Secondary containment testing for: <br />❑ <br />❑ mechanical <br />Model: <br />Sump(s) UST(s) <br />❑ electronic <br />Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ <br />❑ positive shutdown <br />Model: <br />❑ <br />❑ fail safe <br />Serial #: <br />❑ NA <br />e7 ( .. sensor <br />❑ positive shutdown <br />Model: 14 2,0 <br />_7" <br />❑ fail safe <br />Serial = 9 <br />NA * <br />V—t!t 9/ dk=sensor <br />❑ positive shutdown <br />Model: �G3 <br />❑ fail safe <br />Serial #: 6 <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 LIS letter 150-1) <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />EHD I ector: <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 />❑ <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 />S 4_Cie_ je4 44— �a p. F rl'st-r- <br />1 t �� /i i <br />72 <br />TNS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD I ector: <br />Rec a y: <br />Title: <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />