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tN ° SAN JOAQUIN COUNTY <br /> c�..���■ a ENVIRONMENTAL HEALTH DEPARTMENT <br /> y.�Ild 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web: www.sigov.org/ehd <br /> c9� FpR�;P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> &wei�4 Y (q 1 011 <br /> Facilit Address: Service Re uest#: <br /> 1/37 77/Z <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Trainin <br /> !AtdM'1 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial:: ❑ 111 hour hydrostatic 1:1 Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> 11 ❑ electronic Serial:: ElEl1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: El El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> ❑ <br /> El positive shutdown Model: Primary piping testing at: <br /> si <br /> ❑ fail safe Serial #: �ff <br /> El NA minutes <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 /> O 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 /> ElOverfill prevention (see LG letter 150-1) ❑ Other. see below <br /> IPf t c(a-u A <br /> W A„ <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: RM 13 : T <br /> 8/v -1 4 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />