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AqU I lY <br /> °•:�„E�•�oG � SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> w:frlA t 4 <br /> �P5 600 East Main Street, Stockton, CA 95202-3429 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> 9�rF0�� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> mam�ecA d l r J_-2z f m <br /> Facility Address: Service Request M <br /> 49ft 5fZ11_� 5C6q- Z <br /> Onsite Service Technician's Name: ICC Service Technic ianllnstaller Exp.Date: Manufacturer Training: <br /> , 0� a .'3 �3�Z tA (7,/so/0) awe I i <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> mechanical Model: aq Lv 'Z!-oy []1El 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: f1�](�y 11 � ❑ Caldwell System ❑ Other <br /> ❑ line test ro rammed <br /> Leak detector <br /> Vmechanical <br /> Spill bucket ❑ minimum 5 gallon <br /> Model: `Iq LD 2 -&b ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: 0907.119D ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: ❑ 111 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #-. ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ff 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 /> ❑ fall safe Serial #: Note, Please be aware that 21 containment components are required to be tested upon <br /> ❑ NA installation,5 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% [EE11 <br /> Cold start of monitoring panel <br /> El Drop tube with mechanical overfill at 95% Corrosion protection <br /> L1 Overfill prevention (see LG letter 150-1) Other: see below <br /> S 7 Cum Wal-:) kid <br /> I I YA t,� ted — to P-I <br /> THIS FACILITY IS SUBJECT TO REINSP -TION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHQ Inspector: q C- cei e Title: <br /> W - I V4t - <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/171/08 <br />