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I gctu <br />PM!I <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.org/ehd <br />gCiF0 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />7,1161(a <br />MAAI%1�1 <br />Facility Address: Service Request #: <br />10 C,4, 6,30 <br />Onsite Service Technician's Name: IC Service Technician/installer Exp. Date: Manufacturer Training: <br />L94 AddfLS Cd2 <br />U <br />SERVICE <br />Leak detector <br />❑ El mechanical Model: <br />El electronic Serial #: <br />0 line test programmed <br />0 Caldwell System 0 Other <br />Leak detector <br />El <br />0 mechanical Model: <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 electronic Serial #: <br />El Caldwell System 0 Other <br />0 line test programmed <br />- Spill bucket 0 minimum 5 gallon <br />Leak detector <br />El <br />0 mechanical Model: <br />0 Caldwell System 0 Other <br />El electronic Serial #: <br />Primary piping testing at: <br />0 line test programmed <br />psi <br />sensor <br />minutes <br />0 positive shutdown Model: <br />Secondary containment testing for: <br />• fail safe Serial #: <br />UDC(s) Piping <br />• NA <br />Sump(s) LIST(s) <br />sensor <br />El <br />El positive shutdown Model: <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 />El fail safe Serial #: <br />Cold start of monitoring panel <br />0 NA <br />Corrosion protection <br />sensor <br />El <br />El positive shutdown Model: <br />El fail safe Serial #: <br />El NA <br />F-1 <br />Drop tube with mechanical overfill at 95% <br />F-1 <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />I SERVICE <br />W17 T, NMI I I R IM <br />— Spill bucket 0 minimum 5 gallon <br />El <br />El 1 hour hydrostatic 0 Incon TS -STS <br />_Q74. <br />0 Caldwell System 0 Other <br />W7,64 M., <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System 0 Other <br />- Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) LIST(s) <br />❑ <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 />El <br />Corrosion protection <br />L.m <br />Other: see below <br />W17 T, NMI I I R IM <br />_Q74. <br />EH—D —Inspector <br />W7,64 M., <br />4/1 <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />