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Oe+4Ul/1r. C `� \/ <br /> �•'�t•'•O•� SAN JOAQUIN COUNTY <br /> r. tr ENVIRONMENTAL HEALTH DEPARTMENT <br /> to < <br /> sz, <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> PTelephone: (209) 468-3420 Fax: (209)468-3433 Web:www.siQoy.org/ehd <br /> RK <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> GG T4V,, 04-ZDr l <br /> Facility Address: Service Request#: <br /> X535 I�CAA"o A-ft -rwqS L�� <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> -jarud OOurv-p, 07oq o� jI VI- 12161k <br /> 14SPM O 71-15 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: T- Spill bucket Z minimum 5 gallon <br /> El Elelectronic Serial #: ja' 2ri hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: _Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line testro rammed ❑ Caldwell System El Other <br /> Ysensor ,(K WQ, pl Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: ❑ psi <br /> ❑ NA _ - Z 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 required to be tested upon <br /> ❑ NA Installation,6 months after,and every 36 months thereafter. <br /> .Dr p tube with ch nic I overfll at 95°/q ElCold start of monitoring panel <br /> 17-1 Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) B' Other: see below <br /> k r <br /> -rfi4ixxiwq1&t OF 01 61h WIN Q- <br /> THIS FA ILITY IS SUBJECT TO REINSPECTI AT ANY TIME ATE D'S CURRENT HOURLY RATE. <br /> EHD Ins a or: Receiv y: Title: <br /> f <br /> Faala 0 c4 ffNve f-0 uror4 iz-vastI6 of v)k- N wt 7cT T—b-+nk <br /> EHD 23-04 LIST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11117//08 <br /> ti_ <br />