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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT { 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siclov.orcl/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facili Name: Inspection Date: %Ze0 1i Iz J 9 Facility Address: Service Requilbst M —7?zYz2 -1 S 8'2,3). Onsite Service Technician's Name: ICC S rv,g fedi ician/Installer Exp. Date: �X-7 Manufacturer Training: 6 Leak detector ❑ mechanical E o ruv-,J SERVICE SERVICE Spill bucket ❑ minimum 5 gallon K Leak detector ❑ mechanical Model: 04 5y-K"`f THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. ,4? electronic Serial #: Z95 j!f' Spill bucket ❑ minimum 5 gallon ❑ line test programmed ❑ 1 hour hydrostatic ❑ Incon TS -STS Leak detector ❑ mechanical 1 Model: i/%2- 51-k% - electronic Serial # 2955±!!� ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ line test programmed ❑ Caldwell System ❑ Other Leak detector Primary piping testing at: ❑ ❑ mechanical Model: minutes ❑ electronic Serial #: ❑ line test programmed 17 Pill sensor�s k 1` ►�Ky l-h.e Testing for the above components are next due by: ❑ positive shutdown Model: L/)Z '321 ❑ ❑ fail safe Serial #: 7,9Z31 I- Corrosion protection ❑ NA I Other: see below sensor ,positive shutdown Model: fail safe Serial #: Z,37—!J3 t ❑ 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 REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other Received 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 ❑ I Other: see below -6✓ C L-41/ 6e, a..s /' �-tv �"i 1 �L LD v,e� �K, �• �%� THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. EHD Insp Received By: Titie: t �- 0 Ww - i .4p /Y. EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 11/17//08