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ry <br />U!y <br />�• —.E�' o SAN JOAQUIN COUNTY <br />a �y ENVIRONMENTAL HEALTH DEPARTMENT <br />N x <br />.�• <br />... 600 East Main Street, Stockton, CA 95202-302. <br />,P Telephone: (209) 468-3420 Fax: (2Q9) 468-3433 Web: www.siaov.org/ehd <br />S�%FORS <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fa 'lity Name: <br />Inspection Date: <br />*6e, �I 12.10 <br />- -2,-7 - / <br />Fac*Iity�Address: <br />Service Request #: <br />❑ electronic Serial #: <br />' <br />Onsite. Service T chnician's Name: <br />Icc Service Technician/Installer Exp. Date: <br />Manufacturer Train* <br />❑ <br />zz <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />ti►s ��. vi t.". <br />❑ electronic Serial #: <br />' <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 />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shu" own Model: <br />- <br />❑ fail safe:. t Serial #: <br />❑ NA,.," <br />❑ <br />Drop tube . ith mechanical overfill at 95% <br />❑ <br />Drop tube ith mechan c i ove, IIF at 95% <br />❑ <br />Overfill prevention (see LO letter 150-1) <br />EHD 2-04 <br />Rev 1 -1/"8 <br />d <br />7 <br />SERVICE <br />Spill bucket minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -STS., <br />ti►s ��. vi t.". <br />❑ Caldwell System ❑ Other . ;( ; <br />' <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 />§econdary ontainment testi r "} ! <br />? = <br />'6 UDC(s) Piping <br />%AW Sump(s) UST(s) <br />Testing for the above c m o e is ar next due by, <br />Q� 9 M� p 1 4-0, c. ; .4 � s y ' <br />o h+& i 516 4 ?�`' t4ocs. <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 />f <br />14 <br />`aGt (y <br />D'S C�NT HOURLY RATE.. <br />Titl <br />UST SERVICE REQUEST INSPECTION REPORT <br />:1..J.:t;•i.�... <br />ti►s ��. vi t.". <br />i+�. � iii <br />' <br />f <br />14 <br />`aGt (y <br />D'S C�NT HOURLY RATE.. <br />Titl <br />UST SERVICE REQUEST INSPECTION REPORT <br />