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t i°�f••.per SAN JOAQUIN COUNTY <br /> Q: a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sioov.org/ehd <br /> �l FOF <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> ,FAwlity Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> c, Ar, 431-aa66— .5LO-354 Goy- <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> T:�1.5�� Jyf <br /> CT_� <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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ _psi <br /> ❑ fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: 9 ud Sump(s) UST(s) <br /> ❑ NA *-(I( <br /> _sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: 1 -2—/— 41 <br /> ❑fail safe Serial#: Nola Please be scare that T 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%d ❑ 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 /> n / <br /> Rill <br /> r <br /> a,_ D It+S <br /> THIS FACILITY IS SUBJECT 10 REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> ector: Received B <br /> EHD Insp : Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />