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q,4u l ^l <br />SAN JOAQUIN COUNTY <br />rn` { ENVIRONMENTAL HEALTH DEPARTMENT <br />;. 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspec ion Date: <br />_ j q-16 <br />V '[ G <br />0 <br />❑ <br />Facility Address: <br />rvt a Request M <br />❑ electronic Serial #: <br />Onsite Service Technician's Name: <br />IC/CC Service Technician/Installer Exp. Date: <br />Mapufacturer Training:: <br />"QLi <br />/— ✓ { <br />�-fib �� <br />SERVICE <br />awl <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />,. <br />❑ electronic Serial #: <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 ''IItts� <br />Model:Vl�O�`I� i <br />;RPpositive shutdown <br />jqfail safeSerial #: <br />❑ <br />F-1NA �f � 21 <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />O <br />9? Se ensor <br />C*pos itivd Model:T 01%�" <br />shutdown <br />LtII <br />Mail safe Serial #: 161 <br />❑ NA <br />ElDrop <br />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 />awl <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />,. <br />❑ Caldwell System ❑ Other <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 />LIDC(s) Piping <br />Sump(s) LIST(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 />❑ <br />Corrosion protection <br />O <br />Other: see below <br />EHD 23-04 <br />Rev 11/17//08 <br />r� <br />UST SERVICE REQUEST INSPECTION REPORT <br />awl <br />`M?A irgQF22 t i <br />.: u� M; [%. :►� , <br />, <br />,. <br />IEH <br />EHD 23-04 <br />Rev 11/17//08 <br />r� <br />UST SERVICE REQUEST INSPECTION REPORT <br />