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�Op'4'u I N•• C <br />9<ii Oo <br />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.s4gov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />him• B <br />❑ <br />Facility Address: <br />Service uest #: <br />❑ electronic Serial #: <br />npRe <br />OnsiteService Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Training: <br />r�D a� <br />- 'Z <br />`Mnufacturer <br />�/ 4- 1 QVr_I Z K � � a <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REI NSP CTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />ceived <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 />T - -sensor <br />positive shutdown Model: <br />fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />El <br />positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />El <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 ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REI NSP CTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />ceived <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 />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 20 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 />�G5 est ate. <br />THIS FACILITY IS SUBJECT TO REI NSP CTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector, <br />az --J <br />ceived <br />& <br />Title: <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />