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OAq V IN•.0 <br /> 2,• _c�Y ,i SAN .JOAQUIN COUNTY <br /> Q. ENVIRONMENTAL HEALTH DEPARTMENT <br /> y. 600 East Main Street, Stockton, CA 95202-3029 <br /> c4�iFOR��e• <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate• <br /> a bn �0 LI// ho <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: IC Service Technicia staller Exp. Date: Manufacturer Trainin : <br /> (DLID <br /> SERVICE SERVICE <br /> Leak detector <br /> echanical Model: L ddd _F11 <br /> Spill bucket 11 minimum 5 gallon <br /> ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> L1 mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> 1-1 Caldwell System ❑ Other <br /> sensor <br /> F7 El positive shutdown Model: El psi ipiping testing at: <br /> ❑ fail safe Serial #: <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 /> 0 <br /> odel:❑ 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) rEE1 I Other: see below <br /> LLQ. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In Received By: Title: <br /> �C- <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />