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if!Y Inspection Date: A p�gU Q ?•'-�E�"'°•® SAN JOAQUIN COUNTY c Za W < ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Onsite Service Technician's Name: Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd ;P 0 uurte UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Faci 'ty Name; Pv Inspection Date: A Leak detector ❑ Facility Address: L��t 2 ServIw Request #: `` 6, Will Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: . -fo( Manufacturer Training: Z uurte Leak detector ❑ SERVICE Leak detector ❑ ❑ mechanical Model, N THIS FACILITY IS SUBJECT TO REINSPECT N AT ANYTIME ATE 'S CURRENT HOURLY RATE. ❑ electronic Serial #: Recefv By: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed • < LS sensor ❑ positive shutdown Model: �d ❑ fail safe Serial #: i ❑ ❑ 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) SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS THIS FACILITY IS SUBJECT TO REINSPECT N AT ANYTIME ATE 'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other Recefv By: 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 2° 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 1 y AA � rn THIS FACILITY IS SUBJECT TO REINSPECT N AT ANYTIME ATE 'S CURRENT HOURLY RATE. EHD Inspector: - Recefv By: Title: EHD 23-04 Rev 11/17//08 UST SERVICE REQUEST INSPECTION REPORT