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V ty <br />..vc. Lu," <br />SAN JOAQUIN COUNTY <br />W: X <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />0 mechanical Model: <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/ehd <br />0 electronic Serial #: <br />UNDERGROUND <br />STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />I <br />Facility Address: SerAceRequest #: <br />Onsite Service Technician's Name: ICC Service Technician/installer Exp. Date: Manufacturer Training: <br />I--.- )<.- <br />1e— -7111 <br />SERVICE <br />Leak detector <br />El <br />0 mechanical Model: <br />0 electronic Serial #: <br />0 line test programmed <br />El <br />Leak detector <br />0 <br />0 mechanical Model: <br />El electronic Serial #: <br />El <br />0 line test programmed <br />Leak detector <br />E] <br />0 mechanical Model: <br />El <br />El electronic Serial #: <br />0 line test programmed <br />sensor <br />❑ <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />❑ <br />0 NA <br />sensor <br />❑ <br />0 positive shutdown Model: <br />El <br />E] fail safe Serial #: <br />El <br />El NA <br />sensor <br />❑ <br />0 positive shutdown Model: <br />• fail safe Serial #: <br />• NA <br />0 <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket 0 minimum 5 gallon <br />El <br />El 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 />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 />El <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 />Cold start of monitoring panel <br />El <br />Corrosion protection <br />El <br />Other: see below <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />