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Aqu I,N <br />SAN JOAQUIN COUNTY 10 <br />Zr' .tee i 1 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />N; < <br />:. �. 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility ame: <br />Inspection /DDatee:: q <br />Facility Address: <br />Service Request #: <br />r o <br />�5; AC>C) 5-71 ci� —7 <br />Onsite Service Technician's Name: <br />ICC Service Technician/installerExp. Date: <br />�• <br />1 V/e , l$ <br />Manufacturer Training: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT HD'S CURREN HOU LY RATE. <br />❑ electronic Serial #: <br />Received By: <br />I /!v / <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 <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop 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 />'?�/J 3//fl <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT HD'S CURREN HOU LY RATE. <br />❑ Caldwell System ❑ Other <br />Received By: <br />I /!v / <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 />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 />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />A-0) -'ref <br />V • • s7K ��.�- •o Lv I S 1 I�/�'�. el M.t'i11� <br />f�.1r <br />1n w D�.�✓�/�S/ <br />1 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT HD'S CURREN HOU LY RATE. <br />EHD Inspector <br />4��M z <br />Received By: <br />I /!v / <br />Title: <br />/O,-" <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />