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PquIN <br />Inspection Date: <br />SAN JOAQUIN COUNTY <br />Q: -+ <br />y. '.`, <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />C <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si4ov.orci/ehd <br />• — - �p <br />4�%FORS <br />Onsite Service Technician'sName: <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />G,12 t_ <br />❑ mechanical Model: <br />THIS FA,CAITY IS SUBJECT TO REINS C ION T AN TI E T EHD'S CURRENT HOURLY RATE. <br />LAddress: <br />Facility <br />`7 & 67 <br />Title: <br />Service Request #: <br />�12-00 S "7--L-,> 4--� <br />Onsite Service Technician'sName: <br />Leak detector <br />ICC Service Technician/Installer Exp. Date: <br />Ma ufacturer Training: <br />❑ electronic Serial #: <br />❑ <br />0 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FA,CAITY IS SUBJECT TO REINS C ION T AN TI E T EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />Title: <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 />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />rEl <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 LIS letter 150-1) <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FA,CAITY IS SUBJECT TO REINS C ION T AN TI E T EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Title: <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 />Sumps) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note:Please be aware that 20 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel rte- ' •cam -X--so <br />❑ <br />Corrosion protection <br />rEl <br />Other: see below <br />4- 4Q1 <br />THIS FA,CAITY IS SUBJECT TO REINS C ION T AN TI E T EHD'S CURRENT HOURLY RATE. <br />or: c ive By: <br />EHD Inspect\1 <br />g�z&� <br />Title: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />