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Aqulk <br /> SAN.IOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web: www.si.gov.org/ehd <br /> Q�tF0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspecti n Dale.. <br /> 920 Favi 4 646' C/Facility Address: Servic Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Traini g: <br /> SERVICE SERVICE <br /> Leak detector �� Spill bucket El minimum 5 gallon <br /> 10 V mechanical Model:' � ' L� El 1-11 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial #: 0 ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Madel: Spill bucket F1 minimum 5 gallon <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> El line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic 0 Incon TS-STS <br /> ❑ line test proQrammed ❑ Caldwell System 17 Other <br /> sensor <br /> El positive shutdown Model: El psi piping testing at: <br /> E] fail safe Serial #: p <br /> 1-1 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 /> ❑ fail safe Serial #: Note: Please be aware that 21 containment components are required to he 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) ❑ Other: see below <br /> i PJ I (j BU/— cam' 1*--J �- <br /> 9121 b1i N2 bi,A lwvi j <br /> 1 <br /> r <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe � Receiv y: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />