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>:�t•.,c` SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www siQoy.or0/ehd <br /> • �'�[IFORN`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> owtlCali- <br /> y� <br /> Facili d ss: Service Request : <br /> o \4b5olmi �� , 6061x4 <br /> Onsite Service Technician's Name: ICC service Tech niciantinstaller Exp.Date: Manufacturer Training: <br /> 52s Z �16a�-3► M **JL zz Z <br /> SERVICE SERVICE <br /> Leak detectorQy1 t�l� Spill bucket ❑ minimum 5 gallon <br /> { mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> wJ <br /> El electronic Serial#: �_ ❑ Caldwell System ❑ Other <br /> El line test ro rammed <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> _Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ _psi <br /> ❑ fail safe Serial#: 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 /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note: Please be aware that 2°wntainment components ere requiretl to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> ❑ _Drop tube with mechanical overfill at 95% 110300ther: <br /> d start of monitoring panel <br /> ❑ _Drop tube with mechanical overfill at 95% rosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) see below <br /> b W �qjS I;Jr IN { l L{ <br /> ip Gb a4& <br /> [0 rr SY <br /> THIS FACILITY IS SUBJECT TO REINSPEgION ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD!nso r Re i d Title: <br /> D 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> V 111171108 <br />