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SAN JOAQUIN COUNTY <br /> a' �+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> y? ' 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.si.gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> UQA66 �V1C�s ��`m 1_6ri <br /> Facili ddress: Service Request#: ) <br /> L" S CD aA �YL ()OVr __1_)3( <br /> Onsite Service Tec ician's Name: ICC Service Technician/Installer Exp. Date a ufactTrpining:D <br /> OLI '0 <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 <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: ElEl1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ <br /> El electronic Serial: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor <br /> El El positive shutdown Model: Ell <br /> Primary testing at: <br /> ❑ fail safe Serial #: <br /> minutes <br /> El 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 /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> .J <br /> 5 ro tube with mec nical overfi I at 95% Cold start of monitoring panel <br /> 101,0 <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LIS letter 150-1) Other: see below C4 <br /> Vim► G RD(/ VIS o <br /> DO i - Cove �e�l sP�► J <br /> L� <br /> in 6LU 45 UA,r Sor sl�l <br /> + 84 11 W - P ss <br /> OM ,;L K GaL I v:- I a1.g", 5`?e j I L{DO = (I's — l 2-S C' .5 <br /> THIS FACILI Y IS SUBJECT TO REINSPECT104 AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E n pectora 1 Recei By/� Title: <br /> AA <br /> U n.4lblPr poSrjNG 501 �L SCP Sun��— L ft&of WVt`6— OW pMduO I a t4nlr 4n }-o <br /> EHD 23-04 V rnP UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />