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PAW N � 16 <br /> COUNTY <br /> �o. t.co SAN JOAQUIN COU <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .y <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 /> 4�iFORa <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> G� 4 F� MNF 817*01 <br /> Facility Address: Service Request#: <br /> /4� � i GI �1' ►'7�� S24D�OS3 <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> v2 -- 8368S`Z lfr f t� <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> 11 mechanical Model: ❑ ❑ 1 hour hydrostatic D Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El (71mechanical Model: El 171 hour hydrostatic ❑ 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 /> El electronic Serial #: <br /> El Caldwell System Ll Other <br /> 17 line tes ro rammed <br /> ac—PRVU nsor Primary piping testing at: <br /> Il positive shutdown Model: 71q-3'10 -k7 ❑ psi <br /> ❑ fail safe Serial #: '7,M3,,7-1 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 /> D NA <br /> sensor Testing for the above components are next due by: <br /> ❑ 0 positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 2°containment components are required to be tested upon <br /> D NA installation,6 months atter,and every 36 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 /> ,�.v..►� G � �' `��' 7 2 = y".3°1(, �' 1[/t" Z <br /> U <br /> e <br /> 4 �- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Recei y: Title: <br /> UST SERVICE REQUEST INSPECTION REPORT <br /> EHD 23-04 <br /> Rev 11117!108 <br />