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AqurN <br /> �q•��•ca� � SAN.IOAQLi1N 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.s1gov.or4/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> i/ a 2-//0 <br /> Facility Address: Service Request#: <br /> 1 ()D 91 S�66 S29 9-5 <br /> Onsite Service Technician's Flame: ICC Service Tech nicianllnstalter Exp.Date: Manufacturer Training: <br /> ( J P — 0 Ms/ il 4489 k/'iz/ip <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: El Caldwell System El Other <br /> Ll line test programmed <br /> 1 <br /> Leak detectorSpill bucket ❑ minimum 5 gallon <br /> El [Imechanical Model: ElEl1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System ❑ Other <br /> El 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 /> ❑ ❑ positive shutdown Model <br /> ❑ fail safe Serial #: Note: Please be aware that 2°containment componeris are required to be tested upon <br /> ❑ NA installation,5 months after,and every 35 months thereafter. <br /> -D, � 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 /> x ZVz- y Y BIZ `fir X z- <br /> Y �Z -7 (A] -7 t41-3 <br /> ' 14d h 4tL� *6 uVIA <br /> THI FACILITY ISS BJECT TO REINSPECTION AT AN TIME T EHD'S URRENT H RLY RATE. <br /> --T --t A 16!,� <br /> EMD Inspector: R ceived By: Title: <br /> UST SERVICE REQUEST INSPECTION REPORT <br /> EHE 23-04 <br /> Rev 11117//68 <br />