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:<,;92555171888 Line 1 0 yn,d vvrwtveea yvve• e . 4:42 a.m. 12-16-2009 313 - - <br />:-'. �X MJIRONMENTAL HEALTH DEPARTMENT <br />'4R <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />0a fq PM <br />�� �" a <br />Inspectio Date. <br />/Z'7 3) 0� <br />Facility Address: <br />r e tih o� n?, ` c, !Z <br />Service Request #: <br />Si2 oto S S 715,16 <br />Onsite Service Technician's Name: <br />ICC Service Technici7nstaller Exp, Date: <br />Manufacturer Training: l <br />❑ line test programmed <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />SERVICE <br />,}SERYIPE <br />Leak detector <br />G fJ �, <br />L�7'A Spill b ck t ❑ minimum� J 5 gallon <br />❑ mechanical Model: <br />X1 hour hydrostatic ❑ Incon TS -STS <br />❑ electronic Serial #: <br />❑ Caldwell System Other <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 />Secondary containment testing for: <br />❑ positive shutdown Model: <br />UDC(s) Piping <br />❑ fail safe Serial : <br />Sump(s) UST(s) <br />❑ NA <br />Testing for the above components are next due by: <br />sensor <br />® <br />❑ positive shutdown Model: <br />Cold start of monitoring panel <br />❑ fail safe Serial #: <br />Corrosion protection <br />❑ NA <br />Other: see below <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 950 <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />EHO 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />,}SERYIPE <br />G fJ �, <br />L�7'A Spill b ck t ❑ minimum� J 5 gallon <br />ns <br />X1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />VN <br />❑ Caldwell System ❑ Other <br />Tide: <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System R 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 atter, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />EHO 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />- 0 v e' r r One, - � Dupt- reolk., n <br />ns <br />P r <br />,7X <br />y <br />1 %/ <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector. <br />Riv-1 <br />VN <br />Received By. <br />Tide: <br />EHO 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />