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ut <br /> SAN JOAQUIN COUNTY `^ <br /> r. .r ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> • �7r' Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.orq/ehd <br /> � vP <br /> pClFORa <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspe <br /> FacilityAddress: Se ice Re uest#: <br /> 32-5D VXA4- 4,k'j <br /> Onsite service Technician' Name: IN;serviceechniCianAnstalle Exp.Date: Manufacturer Training: <br /> a� 1 V 0- <br /> 16 VW <br /> ► , <br /> SERVICE SERVICE <br /> Leak detector / L: Spill bucket [I minimum 5 gallon <br /> ❑ echaniCal Model: ?l `/ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test ro rammed <br /> Leak detector �/ Ovl Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: V 1 I ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> l�electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> fl—Leak detector Spill bucket ❑ minimum 5 gallon <br /> [TrAechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> lsOelectronic Serial ANe— ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El _psi <br /> El fail safe Serial #: minutes <br /> ❑ NA <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 /> ❑ fail safe Serial #: Note: Please be aware that 2 contamment corroonents are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95%q ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95%q ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ()A 6 re A <br /> 3 <br /> THIS FACILITY IS SUBJECT TO REINSPE T T ME AT EHD'S CURRENT HOURLY RATE. <br /> HD Inspector Recei y Title: <br /> WV <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/171/08 — <br />