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4qu�N <br /> SAN JOAC2UVN COUNTY <br /> ~`r' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web: www.s'qov.org/ehd <br /> �4G:1FpR�,P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> � 1 of <br /> Facility Address: I WService Request#: <br /> I qLw I Iy�,l�,„�� spa � <br /> Onsite Service Technician's Name: ICC Service Tech nicianllnstaller EX Date: Manufacturer Training: <br /> act, r MrLv+ 2 4- ? - u7 t� <br /> SERVICE SERVICE <br /> Leak detector 5L Spill bucket J9 minimum 5 gallon <br /> ❑ ❑ 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 /> El ❑ mechanical Model: El LJ1 hour hydrostatic 11 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 #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ Elpositive 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 components are required to be tested upon <br /> ❑ NA installation,n"months after,and every 35 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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rece'Ved®y: Title: <br /> Ll`�7P-el e'er v <br /> EHD 23-04 Fry 7 �� � ��-7 0 UST SERVICE REQUEST INSPECT40N REPORT <br /> Rev 11 1171108 <br />