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oPquly o . <br /> SAN JOAQUIN COUNTY <br /> yi ENVIRONMENTAL 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 /> d�rFO'r�N`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> �w►�� w� G�L)�1 to Z6 D <br /> Facility Address: Serv' a Request#: <br /> 50 b Int . GGt arkvL wa � � 1��� �'n vv 860 <br /> Onsite 3 j <br /> Onsite Service Technician's Name: ICC e i e Techni ian/In taller Exp.Date: Manufacturer Training: <br /> l u 3d « r rsl r l OP Pi <br /> st!,V� <br /> SERVICE I `lf` c4;Z0/1 SERVICE <br /> Leak detector �{ <br /> ❑ mechanical Model: Spit dXminimum 5 gallon <br /> ❑ ❑ electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System I�thetlir4iN v1/t-2 <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ElCaldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> E-1 El mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at:p <br /> si <br /> ❑ positive shutdown Model: <br /> El ❑ fall safe Serial #: ❑ <br /> ❑ NA 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 /> ❑ ❑ positive shutdown Model: <br /> ❑ fad safe Serial #: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA installation,6=nth$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 /> nn .6 I keS p,.e, — &,/- Y i L qe5e--, <br /> i14 r--A il j n c <br /> THIS FACILITY IS tUBJECT TO REIN C AT ANY TIME AT EHD'S CURRENT HOURLY RATt <br /> [EHID I tor. 1 r Re e n Title C,7 a <br /> EHD 23-04 V W UST SERVICE REQUESTINSPECTIONREPORT <br /> Rev 11/17//08 <br />