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o?`�ufN•.c SAN JOAQUIN COUNTY <br /> Q:�..���� -+ -ENVIRONMENTAL HEALTH DEPARTMENT <br /> y. `. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.s'gov.org/ehd <br /> '9�%FORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> j C � C I ��(� iD -� ::i!! <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: <br /> �a Mifactur4r yT�rpinin <br /> V� <br /> <3-0 -T 1 <br /> O <br /> 611542 ntg <br /> SERVICE SERVICE <br /> D5LLeak detector <br /> . �I/� Spill bucket El minimum 5 gallon <br /> mechanical Model: qq ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #:O S(12l Lk 01— ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El El hour hydrostatic ElIncon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor <br /> positive shutdown Model: ❑ Primarppiping testing at: <br /> El El <br /> ❑ fail safe Serial #: <br /> 11 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 /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 20 containment components 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% ❑ 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 /> , <br /> gj <br /> 5 <br /> UPC, 9& bGL kop of 4;ese- V6, -r"nagtyj gf4W <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ictor: Received By: Title: <br /> CSN. <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 , <br />