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SAN JOAQUIN COUNTY <br />a r-etr Gym ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />' Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.org/ehd <br />��GIFOR�`P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />n 14 � <br />Inspection Date: <br />-7_�� _ ICS <br />Facill-V Address:Serv'ce <br />Request: <br />Onsite Service Tec tan' Na e: <br />``- <br />ICC Se ice TechnicianlInstaller Exp. Date: <br />'7-�� <br />Manu turer Training: <br />Tt le <br />i <br />❑ line test programmed <br />tl <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />\AAL kk- 411 VAR-, -THIS <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />EHD Inspecto . <br />'4:���5� <br />7 <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 />SERVICE <br />\AAL kk- 411 VAR-, -THIS <br />Spill bucket minimum 5 gallon <br />I$� <br />1 hour hydrostatic ❑Incon TS -STS <br />Caldwell System ❑ Other <br />EHD Inspecto . <br />'4:���5� <br />7 <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 />❑ <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 />\AAL kk- 411 VAR-, -THIS <br />FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspecto . <br />'4:���5� <br />7 <br />Recei By: � <br />Title <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />