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°PAutN SAN JOAQUIN COUNTY <br /> �.•Et o� <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> yQ:a,��� •'a <br /> . 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.siaov.org/ehd <br /> '9<iFORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> stpiot 1IZ31Ur1 <br /> Facility Ad ess: Service Request#: <br /> I I C !;f4/Z!;7-? 7j2- <br /> Onsite Service Technician'sName: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> J �2S ZZ�6 u 1 L Ii <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El electronic Serial: ElEl1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> 11 Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El electronic Serial: El 1 hour hydrostatic El Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: E] ❑ 1 hour hydrostatic 1:1 Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> sensor <br /> El positive shutdown Model: ElPrimarpS piping testing at: <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 /> ❑ 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) ' Other: see below <br /> -- <br /> 0, 11 2 1 STES <br /> �D <br /> THIS FACILITY IS UBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Recei d B Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />