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�• -�E_�'•oG SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> a: a <br /> y. '. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www,slgov.org/ehd <br /> 9�/Fa•¢�a <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> P-'-- a zl 'K6 !^ �- J <br /> Facility Address: r Service Request#: <br /> /Loo 62/ `% <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> f <br /> SERVICE SERVICE <br /> Leak detector l Spill bucket El minimum 5 gallon <br /> ❑ mechanical Model: L _ ❑ El1 hour hydrostatic ❑ Incon TS-STS <br /> _electronic Serial #: — ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Lj I Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: L I El EJ1 hour hydrostatic El Incon TS-STS <br /> �electronic Serial #: El 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 /> 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 /> ❑ fail 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 awara that 2'containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> 1511 <br /> ❑ Drop tube with mechanical overfill at 95% Cold start of monitoring panel U —.J- <br /> Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Other: see below — <br /> — S -fir- , 6 Lto L <br /> ::::. r5l, <br /> i 5 Sr�VL Sl^ f- I a r/iv a <br /> 1- ,._2 <br /> -------✓ li � /�,..� ��?-t.r G /) -- I�� 3 ��vr Mfr`1 w�`.+..�It�.� /� �1�vr� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME T EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received BWo <br /> i Title: <br /> l <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17/108 <br />