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ot+4�I y .c <br /> ?' .'•O,o `' SAN JOAQUIN COUNTY "1010 <br /> r. 1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> <: a <br /> w: < <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> �P <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sioov.orglehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> RtUY 4�i . — /J—/V <br /> Facility Addr ss: Service Request#: <br /> 4g5o uc(c,le CevC- L-J-, S2oo551 0 <br /> Onsite Service Technician's Na e: ICC S rvice Technician/Installer Exp.Date: Manufacturer Training: ; <br /> M i 1� c.••�s rt,� �. <br /> t=E Me,- <br /> SERVICE SERVICE <br /> Cig�Leak detector - t. <br /> St-mechanical Model: FE��ro Spill bucket El minimum 5 gallon <br /> El electronic Serial #: f�`6 (oogc El EJ1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> L1 Caldwell System El Other <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 ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ID mechanical Model: 1:1 El1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System El Other <br /> El line test programmed <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> F-1 ❑ fall safe Serial #: El Primary <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 /> ❑fail safe Serial #: <br /> Note: Please be aware that n containment rths thereafter are required to be tesleC upon <br /> ❑ NA installa4pn,6 months after,and every 36 rtgn(hs Iherea(ter. <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'*.. <br /> 1 <br /> I T � <br /> 4" S j. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect Received By: Title: <br /> EHD 23-04 �,/•///l UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />