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ot`4utM c <br /> ?•'��''•P SAN JOAQUIN COUNTY <br /> —ter y ENVIRONMENTAL HEALTH DEPARTMENT <br /> N I { <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> 4�%FO'Ra <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> L <br /> � 11i'� <br /> Fact'FaciWy Address: Service Request#: <br /> ,�L,Lm W ww Gi 0 b S_ -Ti�7 <br /> Onsite Service Technician's Na e: ICC Service Technician/ins Her Exp.Date:_ I Manufacturer Training: <br /> SL Sj_ <br /> SERVICE SERVICE <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 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 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 /> 91 sensor tWicAttil Primary piping testing at: <br /> ❑ positive shutdown Model: U�L `f M ❑ psi <br /> 'f ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> -_sensor CK.,Ntr Secondary containment testing for: <br /> ❑ positive shutdown Model: VrL 401 UDC(s) Piping <br /> ❑fail safe Serial#: ti Sump(s) UST(s) <br /> ❑ NA <br /> sensor 0',JNLtV, Testing for the above components are next due by: <br /> �. ❑ positive shutdown Model: UA` `O <br /> ❑ fail safe Serial#: Note: Please be aware that 2°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 LIS letter 150-1) ❑ Other: see below <br /> N s'k, 7 <br /> S,Jc AL `(I GN" .. a <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector Re y: TitlJ <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />