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oF4 IN• SAN JOAQUIN COUNTY • <br /> u: ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.siaov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> T -t Z 10114,101 <br /> Facility Address: Service Request#: <br /> - (UO 57676 <br /> Onsite ServiceTechnician's Name: IICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> ik±L AV- `7 3(a?Sb-O VK A-2,-7 !;Z?- <br /> SERVICE <br /> Z"1SZ2SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ <br /> ❑ electronic Serial El1 hour hydrostatic ❑ Incon TS-STS <br /> #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ElCaldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El El positive shutdown Model: Elsi <br /> ❑ fall safe Serial #: p <br /> E] NA minutes <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 2°containment components are required to be tested upon <br /> ❑ NA nstallabon,6 nwnths after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% Cold start of monitoring panel rAK EVIE, <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> d <br /> V444 <br /> d4JA <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rece'v y: Ti <br /> /✓I I V'/ <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />