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°PqutN C ?•''��''•Op SAN .lOAQUIN COUNTY 2 -err ENVIRONMENTAL HEALTH DEPARTMENT N. 600 East Main Street, Stockton, CA 95202-3029 F. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility 5 Name: Inspe on ate: �'l� Facility ss ��/ 11 Se�r7 st #: D 0 Onservice Technigian's Name: ICC Service Technician/Installer Exp, Date: Soap Manufacturer Training: SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: 8106jorm,• ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) r CIS SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other 8106jorm,• Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel Corrosion protection ❑ Other: see below �� U EHD 23-04 Rev 11/1 7//08 UST SERVICE REQUEST INSPECTION REPORT 8106jorm,• Inspector - OWN ..1� . iii•. i♦ ' �� U EHD 23-04 Rev 11/1 7//08 UST SERVICE REQUEST INSPECTION REPORT