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OQ`qu ty. O <br /> SAN JOAQUIN COUNTY <br /> 2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> a 1a <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 4�tF ORN\ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> r�bd MPJ' 9 2 P z <br /> Facility Address: Service Request#: <br /> /q1K QkAnL4SZ-T 15006q_996 <br /> Onsite Service Technni ian's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> C rte/t4LC,� 53236 — t 11 13 fe-&-hr N�A <br /> SERVICE SERVICE <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed ElCaldwell System ❑ Other <br /> _Leak detector Spill bucket El minimum 5 gallon <br /> El El mechanical Model: El El1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#:❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El - si <br /> ❑ fall safe Serial#: p <br /> ❑ NA _minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial M Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA installation,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) R8 Other: see below , <br /> rA This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> t S "L4— <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT 'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received-BTitle: <br /> _ I d <br /> EHD 23-04 V UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/08/70 <br />