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A4iN. <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> w. < <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sioov.org/ehd <br /> dtfkdRa�p <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> «i c `JR-EJt7/ 4� <br /> Onsite Service Technician's Name: ICC Service Technicianfinstaller Exp.Date: Manufac r Trains <br /> SERVICE SERVICE <br /> aVy-z Leak detector , //Op Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model:V/— ��f`�4 ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> 9 IAkW Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: 2 u ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> Prelectronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> jW 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 /> ❑fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA El_sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note: Please be aware that P containment components are required to be tested upon <br /> ❑ NA Installation,a months after,and every W 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 /> / M4 cinpr.�L l,..k5 G 35 <br /> 30 �P <br /> THIS FACILITY IS BJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In dor: d By: T'I <br /> EHD 23.0 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 111171108 <br />