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O.P4 U I N• •.0 SAN JOAQUIN COUNTY ar -� ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd oq � i F o'RN�P UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: SERVICE Inspect' n Date: S� C� � ❑ mechanical Model: �U�L�lo� Facili y Address: ❑ Incon TS -STS Service Request #: -1 d 1 . j S koc,�G�1 S/Z, ov S 8vZ Onsite Service Technician's Name: ❑ minimum 5 gallon ICC ervice Techni 'an/Installer Exp. Date: � 2s/ l /it/<�� Manufacturer Training: 4&1,e—d,,j (leN Pep (, ❑ SERVICE SERVICE Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ Incon TS -STS ❑ line test programmed ❑ Caldwell System Leak detector ❑ ❑ mechanical Model: ❑ minimum 5 gallon ❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ line test programmed Leak detector ❑ ❑ mechanical Model: Spill bucket ❑ electronic Serial #: ❑ ❑ line test programmed ❑ Incon TS -STS sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA psi sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: Secondary containment for: 3-1; r/ testi -7 ❑ NA UDC(s) sensor ❑ ❑ positive shutdown Model: UST(s) ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) EHD 23-04 Rev 11 /17//08 UST SERVICE REQUEST INSPECTION REPORT SERVICE t,/ err, So , -elm' Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment for: 3-1; r/ testi -7 UDC(s) Piping Sump(s) UST(s) Testing for the above components are next due by: Note: Please be aware that 21 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below EHD 23-04 Rev 11 /17//08 UST SERVICE REQUEST INSPECTION REPORT t,/ err, So , -elm' -9� /tih THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspector: W /lam Received By: Title: EHD 23-04 Rev 11 /17//08 UST SERVICE REQUEST INSPECTION REPORT