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oP4V18 <br /> SAN JOAQUIN COUNTY 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> w < <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Y. Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> AAA- ou Am ql 1)9 <br /> Fa i i dress: Service Request#: <br /> � - 1 / q <br /> Ons]a ervice Technici n'sName: ICC Service Technician/Installer Exp. ate: Me cturer Training: <br /> �b - iD P 359 /a <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: _Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ <br /> ❑ electronic Serial#: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ El mechanical Model: ❑ <br /> ❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> _UD�lYje sensor <br /> positive shutdown Model: tiz Primary piping testing at: <br /> ail safe Serial#: El 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#: Note: Please be aware that 20 containment components are tenured to be tested upon <br /> ❑ NA installation,6=nths 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 /> 1 <br /> THIS FACT IS SUBJECT TO REINSPECTION TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD a Received By: Titl <br /> EHD 2 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 17V <br />