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OqQ IN C <br />?• SAN JOAQUIN COUNTY <br />y ,{ 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 />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICEEST INSPECTION REPORT <br />Facility Name: �C _ <br />Inspection Date: <br />Facility Address: <br />Service Request #: <br />O : it Service Technician's Name: <br />f C Service Technician/Installer Exp Date: <br />Manufacturer Training: <br />❑ <br />❑ mechanical Model: <br />❑ Caldwell System ❑ Other <br />SERVICE <br />Leak detector <br />❑ ❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: <br />Spill bucket ❑ minimum 5 gallon <br />❑ line test programmed <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Primary piping testing at: <br />❑ electronic Serial #: <br />psi <br />❑ line test programmed <br />minutes <br />sensor <br />positive shutdown Model:IQ _3 <br />Secondary containment testing for: <br />❑ fail safe Serial #: <br />UDC(s) Piping <br />❑ NA <br />Sump(s) UST(s) <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Note: Please be aware that 21 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ fail safe Serial #: <br />Cold start of monitoring panel <br />❑ NA <br />Corrosion protection <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />Drop tube with mechanical overfill at 95% <br />❑ <br />r❑ <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 />❑ ❑ 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 />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 21 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 />'SAI.... � ■ r;!♦ � % � ii ,� ' �' <br />11 11 1 I <br />10 16-2 OF -414i IN I WA 611141111 --111 *0111111111tel :41 uf��Wva I I J, ITT% 1:11:11 <br />�J® V V <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />