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1 Y •at,4t!!lY., <br /> ' fir.-'•y SAN JOAQUIN COUNTY <br /> L ^rti- •1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.orq/ehd <br /> �dCi F ORN`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> rlora a 7-17-a g <br /> Facility Address: Service Request#: <br /> `o 54DO56 53 <br /> Onsite Service Technician's Name: I ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ElCaldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: L1 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed 1 <br /> ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> El fall safe Serial #: ❑ psi❑ 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 /> ❑ fail safe Serial #: <br /> Note: Please be noaware that n containment rths thereafter required to be tested upon <br /> ❑ NA installation,6 monUs after,and every 36 rtwnths Uereafter. <br /> ❑ Drop tube with mechanical overfill at 95% Ad7 Cold start of monitoring panel a UtL <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection .15 <br /> ❑ Overfill prevention (see LG letter 150-1) Other: see below ,,,J, Lk Z�3 <br /> �(� s .l Cs; ooz�yy t¢po <br /> I tr' O �+� lrr Q 7 ` V�%5 <br /> Ch, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION NY TIU AT RHOS CURRENT HOURLY RATE. <br /> EHD Inspector: e i Title: <br /> EHD 2M4 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />