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SAN .10AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ;. 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: bJL Inspection Date: C. ❑ mechanical Model: THIS FACILITY IS SUBJECT TO REI SP TI N AN IM T EHD'S CURRENT HOURLY RATE. Facility Address: -v,3 c ve y: Service Request #: tz-C.) lir LIP (7b-*" Onsi a Service Technician's Name: Leak detector ICC Service Te Installer Exp. Date: Manufacturer Training: ❑ electronic Serial #: ❑ Y--. �ev�2-13 SERVICE bJL Leak detector ❑ ❑ mechanical Model: THIS FACILITY IS SUBJECT TO REI SP TI N AN IM T EHD'S CURRENT HOURLY RATE. ❑ electronic Serial #: c ve y: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ 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 LIS letter 150-1) SERVICE bJL Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS THIS FACILITY IS SUBJECT TO REI SP TI N AN IM T EHD'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other c ve y: 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 21 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. Cold start of monitoring panel ❑ Corrosion protection ❑ I Other: see below 5;- bJL THIS FACILITY IS SUBJECT TO REI SP TI N AN IM T EHD'S CURRENT HOURLY RATE. EHD Inspector: c ve y: Title: &T 7/ EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 11/17//08