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O1A I N•.0 <br /> SAN JOAQUIN COUNTY <br /> Q' ? ENVIRONMENTAL HEALTH DEPARTMENT <br /> y _ 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> C9<iFORa`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Na Inspection Date: <br /> fi�,, <br /> V k <br /> Facili A dress: l A) Se is Request M <br /> / 'r �/ <br /> (l✓ vV V�/l �akI 7/V v� <br /> Onsite Service Technician's Name: ICC Service Tech nicianllnstaller Ex .Date: Manufacturer Training: <br /> �3z2�33 , 6 v R� 13 ��� ►btyl I <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial: E] El1 hour hydrostatic ElIncon TS-STS <br /> Ll line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial : ElEl1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> 1-1 Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ <br /> El electronic Serial: El El hour hydrostatic F-1InconTS-STS <br /> El line test ro rammed El Caldwell System 11 Other <br /> sensor <br /> 71 El positive shutdown Model: ❑ Primary piping testing at: <br /> L1 fail safe Serial #: p <br /> El NA minutes <br /> e n s o r 1� may, Secondary containment testing for: <br /> positive shutdown Model. V % UDC(s) Piping <br /> �fail safe Serial #: Sump(s) UST(s) <br /> N A Elsensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 2°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 /> ,V vm,� A �Vb�Mh+�-A bVI <br /> P <br /> THIS FAC)LITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD rt r Received y: LAA,ll Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />