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T <br /> r12 <br /> ff �,. SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> ,2rFOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit" me: Inspection Date: <br /> KQ P6 �nl, � a <br /> Facility Address: service Request#: <br /> Onsite service Technician's Name: ICC S rvi echnician/Installer Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> El ❑ electronic Serial #: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System Ll Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ p <br /> si <br /> ❑ fail safe Serial #: minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> El ❑ positive shutdown Model: <br /> ❑fall safe Serial #: Note: Pease be aware that 2°containment components are required to be tested upon <br /> ❑ NA inslallabon,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> Uvl w( INKAV 0vu' <br /> S <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> e r: Re iv Title: <br /> V P 6 c va <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />