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oP4�lfl. <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> e: < <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> P Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 4�/F iia' <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> b <br /> Facility Address: service Request#: <br /> Vi 1 42-06 Sgd,X15' <br /> O ite Service Technician's_plame: IC Servic Technician/1 Ilex xp.Date: Manufacturer Training: <br /> D� r_J�/ b 711 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> F-1 ❑ mechanical Model: El 1 hour hydrostatic 11 Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ElCaldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> 1:1 ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket El minimum 5 gallon <br /> E] ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #:❑ line test mmed El Caldwell System EJ Other <br /> qE5ro ra <br /> t sensorr� Primary piping testing at: <br /> 3I positive shutdown Model: V ❑ psi <br /> $fail safe Serial #:'ala I�� <br /> ❑ 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 /> El 11 <br /> positive shutdown Model: <br /> ❑ fall safe Serial #: Note: Please be aware that 2 contamnenl components are regi to be tested upon <br /> ❑ NA Installation,6-norths after,and every 36 morins 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 /> 15w 35-2— . J 2e <br /> jillifd4 N be 5 <br /> 10 (avM- k10 ' n r tik, ofw <br /> k hC 15 CVL S1La-a <br /> THIS FACILITY IS SUB ECT TO REINSPECTI N AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect Received By: Title: <br /> '00 to <br /> EHD 23-04 I �If^' 1/N•N f �'-• ` N� UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />