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0.qulty SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> `lI 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.si4ov.orglehd <br /> Ct4{ii=pR��P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> l2 E N GkJjJ 'l <br /> Onsite Service Technician's Name: ICC Service Tech nicianllnstalter Exp. Date: Manufacturer Training: <br /> o FCti► LYrt�t� 5 25 Z�Z-7 - Cit ' [ L (-- <br /> SERVICE SERVICE <br /> if*A�L eak detector `� +'L4 Spill bucket ❑ minimum 5 gallon <br /> 9 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 #: a 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 /> sensor Primary piping testing at: <br /> El positive shutdown Model: ❑ psi <br /> fail safe Serial #: minutes <br /> ❑ NA <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 /> ❑ 171 positive shutdown Model: <br /> fall Safe Serial <br /> Mode Note. Please be aware that 21 containment components are required tc be tested upon <br /> E01 NA installation,6 m©nths 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% Cl Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: ^ Receive y: Ti itle:/ <br /> C O, <br /> UST SERVICE REQUEST INSPECTICN REPORT <br /> EHD 23-04 <br /> Rev 11/17//08 <br />