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oPa�1 ,c <br /> �� P� SAN JOAQUIN COUNTY <br /> Y U ENVIRONMENTAL HEALTH DEPARTMENT <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 /> 4��FOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Faciility1 Name:: 3 Inspection Date: <br /> �k <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> of LUN), N <br /> SERVICE SERVICE <br /> Leak detector Spill bucket minimum 5 gallon <br /> ❑ ❑ mechanical Model: 'iiil-1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <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 /> Leak detector <br /> El mechanical Model: i Spill bucket [I minimum 5 gallon <br /> El ❑ electronic Serial: V 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> O Caldwell System ❑ Other <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 aware that 20 containment components are required to be tested upon <br /> 11 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) El ❑ Other: see below <br /> ti SI I c"{J <br /> J - 1/ 1 n 1 - 9S'� !a L —�- A '�-> > SDi I l 6K�1�•- .l-os�- <br /> 4C4��� %+- S; I S p,-, R I <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD''S CURRENT HOURLY RATE. <br /> EH e Received By: Title: <br /> �Arrt 406.C_(CHAS <br /> EH 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />