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�qu+N <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 600 East Main Street, Stockton, CA 95202-3029 <br /> :. <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web; www.slgov.orIg ehd <br /> 4�1r=pRia <br /> UNDERGROUND STORAGE TANK (UST) PROGRAMA SERVICE REQUEST INSPECTION REPORT <br /> FacilInspection Date: <br /> N�W <br /> q <br /> 1 ZI 7/4 ! <br /> Facility Addresst Service Request#: <br /> N-90 dal ' sed 84d <br /> Onsite Service Technician'sName: /ICC Service Technic ianflnstaller Exp. Date: Manufac//tur@� a rn <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> © <br /> El mechanical Model: El hour hydrostatic ❑ Incon TS-STS <br /> LJ electronic Serial #: LJ Caldwell System [$'Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: ❑ El hour hydrostatic 1-1InconTS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model El El hour hydrostatic LJ Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System ❑ Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ 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 components are required to be tested upon <br /> ❑ NA installation,E 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 /> G'✓� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: 1�fTvJf�r�y� Received By: Title: <br /> J I/ 5r <br /> �e r <br /> EHD 23-04 UST SERVVCE REQUEST INSPECTICN REPORT <br /> Rev 111171!08 <br />