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o¢QuIM o 0 <br />�• �E•r' •o� SAN JOAQUIN COUNTY <br />Q-,� `Z-+ ENVIRONMENTAL HEALTH DEPARTMENT <br />W: <br />. ': 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orq/ehd <br />�qC j F oR��P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Lection Date: <br />Fiacjli� Addass*pip( <br />VAAervice quest #: <br />Onsite Service Technician's N me: <br />ICC Service TechniciaNln ilelEEx D te: <br />—T <br />Manufacturer Training: <br />R TWO <br />VVI 11. i <br />❑ line test programmed <br />al o �� <br />Leak detector <br />❑ <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />k i 1A <br />❑ electronic Serial #: <br />VVI 11. i <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 />❑ 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 />Wlk <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />k i 1A <br />❑ Caldwell System ❑ Other <br />VVI 11. i <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Title: / <br />cSG✓ ✓ - (u t <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 />Corrosion protection <br />❑ <br />Other: see below <br />�1 <br />U f• re I' <br />k i 1A <br />w -7la i'D �a <br />VVI 11. i <br />THIS FACILITY IS SUBJECT TO REINSPECTION #T ANY TIME ATE 'S CURRENT HOURLY RATE. <br />Dor: <br />lkb�r— <br />Received B <br />� �c) <br />1 y <br />Title: / <br />cSG✓ ✓ - (u t <br />EriD 23-04 <br />Rev 11/17//08 <br />V / -UST REQUEST INSPECTION REPORT <br />