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Rquty • <br />°':�E•E'�o SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Y. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />.......... <br />9Gtd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />ame:Inspection <br />Facility Name:-1 <br />�' (I <br />Date: <br />6, , � <br />Facility <br />'jAdd s: <br />Service est #: r1 <br />Opgite Se ice Technician's me: <br />ICC Service Technician Instal err Exp ,Da <br />Manufacturer Training:IV <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />SERVICE <br />�ZS1� '7 tL h <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />/ <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Receive / <br />I Vl <br />1 <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 />❑ 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 LIS leiter 150-1) <br />SERVICE <br />�ZS1� '7 tL h <br />Spill bucket , Rminimum 5 gallon <br />1 hour hydrostatic ❑ Incon TS -STS <br />/ <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REIN PECTION AT ANY StURRENf HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Receive / <br />I Vl <br />1 <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 />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 />l <br />END 23-04 a ST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />�ZS1� '7 tL h <br />/ <br />THIS FACILITY IS SUBJECT TO REIN PECTION AT ANY StURRENf HOURLY RATE. <br />EHD Ins edor: <br />Receive / <br />I Vl <br />1 <br />Title: �- <br />l <br />END 23-04 a ST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />