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?•'--+E�' •o , SAN JOAQUIN COUNTY <br />Q: ■■..���� -� 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 />9�/FORS <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />ua,- <br />Inspection Date: <br />- q -m <br />Facility Address: V <br />1301 LN La)I <br />Service Request #: <br />SRODS7--54146 <br />❑ mechanical Model: <br />Onsite Service Technician's Name: [cc Service Tech ician/Installer Exp. Date: <br />9611,1114 6T 6-54-11z" 3°6" ?W o,� Sv,--recti. <br />Manufacturer Training: <br />AG ` <br />e c� 12-31 <br />IIjr— <br />XI <br />SERVICE <br />8? I lk�c < 11(f 410- <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />EHD Inspector <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 />❑ <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 />❑ 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 />01 <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />8? I lk�c < 11(f 410- <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />EHD Inspector <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 />Seco dary containment testing for <br />UDC(s) Piping <br />Sump(s) UST(s) <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 />29 <br />Other: see below 'lti2 <br />ON sik 4p y4twS INZ <br />8? I lk�c < 11(f 410- <br />he_8<-, wNqd- ti,, 11�x - sl' Ar )-he- <br />43<4- <br />4- <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />THIS <br />EHD Inspector <br />Receiv " By 1 <br />Title: <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />