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oRAufN c0' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT N: < .. 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*gov.org/ehd q�%PORE UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: Spill bucket ❑ minimum 5 gallon Leak detector Facility Address: I e:�O I W I ? art Lr'i � l G% Service Request #: S (Z Ob 5 878 Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: I'Dii, �, s rd �( -5'11 U� e 11-��-16 A SERVICE SERVICE Spill bucket ❑ minimum 5 gallon Leak detector ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon ❑ electronic Serial #: ❑ line test programmed Spill bucket ❑ minimum 5 gallon Leak detector ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ ❑ mechanical Model: Primary piping testing at: ❑ electronic Serial #: ❑ line test programmed Secondary containment testing for: Leak detector UDC(s) Piping ❑ ❑ mechanical Model: Testing for the above components are next due by: ❑ electronic Serial #: ❑ ❑ line test programmed ❑ 81 41 sensor a6 'Trp suiI Other: see below ;Vposltive shutdown Model: 2hA Ofail safe Serial #: ❑ NA 2 sensor << ti `VP -X L^ -111111114C ❑ positive shutdown Model: 0(o ❑ fail safe Serial #: 1 11 u.- ❑ NA C);Mj I q I sensor ❑ positive shutdown Model: qk, ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfi at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE ... •la 1...1iw Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other r . (. Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 21 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection Other: see below EI 23-04 Rev 11/17//08 UST SERVICE REQUEST INSPECTION REPORT ... •la 1...1iw 1�F1 A� �1 THIS FACILITY IS SUBJECT TO REINSPE•AT ANY TIME AT EHD'SHOURLY r . (. EI 23-04 Rev 11/17//08 UST SERVICE REQUEST INSPECTION REPORT