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°?4utN 'c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ••y <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web: www.sigov.org/ehd <br /> C4C%F+pR��P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> t& A4&4o-7 q/ii 1 oq <br /> Facility ddress: Service Request#: <br /> /1,37 *2cr-oC4 Sied D 77/ Z <br /> Onsite Service Technician' Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> L4 �r/1ala8 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ❑ El hour hydrostatic 1:1Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket 11 minimum 5 gallon <br /> El ❑ electronic Serial ❑ El hour hydrostatic ElIncon TS-STS <br /> L1 line test programmed <br /> L1 Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial: ❑ 111 hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Primary testing at: <br /> si <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 2°containment componerts 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 /> A� 5e of <br /> i _ A"- <br /> 411 04kd <br /> f <br /> _ A - <br /> IF <br /> THIS FA ILITY IS SUBJECT TO REIN PE TION AT ANY TI AT EHD'S CURRENT HOURLY <br /> RATE. <br /> EHD Inspector: <br /> EHD 23-04 V UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />