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Paulk <br />�o.�.coG • SAN JOAQUIN COUNTY <br />r.,—. 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 />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fac 'I Name: <br />Inspection Date: <br />Leak detector <br />❑ <br />Facility Address: <br />Service Request #: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Onsite Service Technician's Name: <br />ICC Servke Technician/Installer Exp. Date: <br />Manufacturer Training: <br />�=" (f� r -r 5•c�— <br />2) 17.1 <br />�+�,� •• S 2� i r�,.� 5 2i <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />c <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />,>✓ �' � , � <br />❑ fail safe Serial #: <br />.4.5 >^� �1//sir <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />7 ,� <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />Rece' d <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 />❑ This UST facility is APPROVED to operate <br />E2.S3I's <br />3) <br />SERVICE <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 />c, - o ►w.� , <br />� �� �w <br />❑ Caldwell System ❑ Other <br />c <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />�- <br />Secondary containment testipg for: <br />,>✓ �' � , � <br />UDC(s) Piping <br />.4.5 >^� �1//sir <br />kov-4I- W-7 Sump(s) IF UST(s) <br />Testing for the above components are next due by: <br />7 ,� <br />Loi—e— G' i 7LTHIS <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 />Rece' d <br />Other: see below <br />9H This UST facility is NOT APPROVED to operate <br />EHD 23 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />c._ s /C <br />c, - o ►w.� , <br />� �� �w <br />c <br />�- <br />< ' <br />,>✓ �' � , � <br />�, <br />.4.5 >^� �1//sir <br />7 ,� <br />Loi—e— G' i 7LTHIS <br />FACILIT 51MJECT TO REINSPECTIO T <br />EH&S CURRENT HOURLY RATE. <br />EHD Insp ator:r-= <br />• <br />- %�' �� <br />Rece' d <br />Title: <br />_/9C (� <br />EHD 23 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />