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o1,9A I Iv c <br /> SAN JOAQUIN COUNTY <br /> -r� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web: www.sigov.org/ehd <br /> CqC%FORa`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> P-P_�(aA/L� 19(-2-0 10 <br /> Facility Addre : Service eque t#: <br /> �I2 ?7� 2 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufactur�errlTer,�i ing: <br /> ` ,� Nb r Qc� oci <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket [_1 minimum 5 gallon <br /> 77 ❑ electronic Serial El El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> 11 Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket 1:1 minimum 5 gallon <br /> 1:1 ❑ electronic Serial: ❑ El hour hydrostatic ElIncon TS-STS <br /> Ll line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> F1 ❑ electronic Serial : ❑ El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> El El psi <br /> El fail safe Serial #: <br /> 11 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 /> ❑ 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 a <br /> OV, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins for Received Bye TitjQ_.-, <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />