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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />yi �lf 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Na e: <br />�C S <br />Ins tion Date: <br />v - <br />Vit x/ �# a01�A <br />❑ mechanical Model: <br />Z C) <br />Facility Address:Service <br />. (0 Do s, G j�'�' <br />Request #: <br />5 f �, c? o <br />Onsite Service Technician's Name: <br />®k\A'l`; C <br />ICC Service Technician/Installer Exp. Date: <br />?�2 -r I L <br />Manufacturer Trai ing:��$ <br />C>_p <br />V Ira <br />' 100 ._ u <br />.f <br />IGWAUM <br />SERVICE <br />�C S <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />EHD Ins ,ector. <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 LG letter 150-1) <br />SERVICE <br />�C S <br />9-7- Spill bucket ❑ minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Caldwell System ❑ Other <br />EHD Ins ,ector. <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 />FAI <br />'12 r C vJ rbg <br />�C S <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD Ins ,ector. <br />Received By: <br />zid <br />Title: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />