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oFqul�y oto <br /> x•�.E�••.o SAN JOAQUIN COUNTY <br /> =i .r—crr..- •yy <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> : P. Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sioov.orQ/ehd <br /> 4C%FpRN` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Name: Inspection Date: <br /> V wL,- . ) D <br /> Facility Address: Service Request#: <br /> (p CA X33 om 193 <br /> Onsite Service Technician's Name: ICC Service Technician/nstaller Exp. Date: Manufacturer Training: <br /> VLe <br /> SERVICE SERVICE <br /> Leak detector (") —Spill bucket ❑ minimum 5 gallon <br /> mechanical Model. E] ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial ❑ Caldwell System ❑ Other <br /> ❑ line test ro rammed11 r-A <br /> Leak detectorSpill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: E3 ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detectorSpill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test prograrpmed <br /> 9 v- sensor V(I2f Primary piping testing at: <br /> ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Se ' IM minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fall safe Serial #: Sump(s) UST(s) <br /> ❑ NA ❑ <br /> sensor Testing for the above components are next due by: <br /> El ❑ positive shutdown Model: <br /> ❑fail safe Serial#: Note: Please be aware that 2°cantainment components are required to be tested upon <br /> ❑ NA installation,s montes after,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 /> UCuUm �$Wa hd�5v N/� f I�u�l , �.ti Phan Jsc <br /> Sk - YA /tie n 17Kf7� <br /> "4tV ti hasWehI,a alarm' c� I to�,s eeAS f� �Ci <br /> A <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT Al.Y TIME AT EHD'S CURR NT HOU LY RATE. <br /> EHD ivaid B : Title: <br /> A 1. I� �nl Ai&r� Wa3 u "W ct S <br /> {1�/1 A�/I �D�NN "�' I� UST SERVICE R/EQUESTINSPECTION REPORT <br /> Rev O111 n//08 ll'-err '' u1�s G � til 5ern 4l � AW (htj,7) <br />