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r �quiM `ort' SAN JOAQUIN COUNTY e-� ENVIRONMENTAL HEALTH DEPARTMENT N' { 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433Web: www.sigov.org/ehd gti`r'�ar' UNDERGROUND STORAGE T (UST) PROGRAM SERVICET INSPECTION REPORT a op Inspection Date: / —. Y® / Service Request M Lae, Onsite Service Technician's Name: ICC S rvice Technician/Installer Exp. Date: Manufacturer Training: ii !Si Vw- jc_5 j, 1 1 s�. SERVICESERVICE I /11— CO, I ism le., 4c, THIS CILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Insp C Recei y Title: r EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 11/17//08 Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector echanical Model: ❑ electronic Serial #: 0 1 O t ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) I /11— CO, I ism le., 4c, THIS CILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Insp C Recei y Title: r EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 11/17//08 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 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 20 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 I /11— CO, I ism le., 4c, THIS CILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Insp C Recei y Title: r EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 11/17//08