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0 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fa 'lity <br />�kxb# <br />Name: <br />0 1210 f,�. 6mw,,1 I4. <br />Inspection Date: <br />T — -2 7— 0.9 <br />Facility Address: f <br />ci 6/ - <br />Ser( ice Requestt/ #: <br />"SKIJ S ASR -0,0 S� c <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Trainin : <br />1 <br />C.0 4, <br />— O <br />Ko., ' p <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />�. (.►91 �� <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 />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <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 />SERVICE <br />Spill bucket )0 minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS-STSII <br />❑ Caldwell System ❑ Other <br />�. (.►91 �� <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 />6 P ii Son, <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />9econda containment testi f r J k4ky� <br />3 '�G q j <br />�6 UDC(s) Piping <br />t4< Sump(s) ,}�!� UST(s) <br />T sing for the above cgmpo e�t har* ne`x��e by- <br />-�%", <br />5% 4 7/1� <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />EHD 23-04 / <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />�. (.►91 �� <br />THIS FACILITY IS SUBJECT TO REINSPEr <br />6 P ii Son, <br />?0711AM--- -1 <br />Wi-.13=05 <br />EHD 23-04 / <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />