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�Rqu r y. <br />SAN JOAQUIN COUNTY <br />..�tbor: _ ;G <br />y ENVIRONMENTAL HEALTH DEPARTMENT <br />y'. { <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />q�%FOtR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facil' Name: <br />Mitt, s� Y tn.Kz�, �&, � �� <br />Inspection Date: <br />0� of la <br />Facility Address: <br />5D5 MeU <br />Service Request #: <br />00 � o 2AI <br />Onsite Service Technician's Name: <br />�� <br />r p. Date: <br />ICC Service Technician/Instal 1 <br />g l <br />Manufacturer Training: <br />1 1 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />i <br />IT J •_%i ��&/l �l� !../. I►'.. ivies L !. �L� I 6i. ...'. <br />❑ electronic Serial #: <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 />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />❑ <br />Overfill prevention (see LIS letter 150-1) <br />SERVICE <br />pill bucket ❑ minimum 5 gallon <br />hour hydrostatic ❑ Incon TS -STS <br />i <br />IT J •_%i ��&/l �l� !../. I►'.. ivies L !. �L� I 6i. ...'. <br />,PMaldwell System ❑ Other <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 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 />❑ <br />Other: see below <br />V <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />i <br />IT J •_%i ��&/l �l� !../. I►'.. ivies L !. �L� I 6i. ...'. <br />V <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />