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C SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> `I 600 l=ast Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fix: (209)468-3433 lRlek�: www.s' ov.or lehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRp►11PI SERVICE REQUESTINSPECTION REPORT <br /> Inspection Date: <br /> Facility Name:,. p,,. FJ r� [ I I Q <br /> AA OL ' ( ` Service Request#: <br /> Facility Rddress: 2t�� �G S <br /> Z3Gi �S ���u1n �'� <br /> Onsite Service Technician's Name: LCC Service Technicianllnstaller�xp. pate: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> L-LI1 <br /> ❑ ❑ mechanical Model ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial #: ❑ Caldwell System - Other <br /> ❑ line test ro rammed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> ECEIsensor Primary piping testing at: <br /> ve shutdown Model: ❑ psi <br /> fe Serial #: minutes <br /> sensor Secondary containment testing for: <br /> ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA ❑ Testing for the above components are next due by. <br /> sensor <br /> ❑ ❑ positive shutdown Model: <br /> ❑fail safe Serial #: Note. riease beaware tr.al 2�conraicrner`Cnrnponents ore r�qr.-d.o <br /> LE NA ms;ail7aor,o r crths atlnr.and .-;3G rnor_;'ns•her•:'.n!?.r <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) i Other. see below <br /> Com-/ <br /> THIS FACILITY IS SUBJECT TO REINSANY TIME AT EHD'S CURRENT HOURLY PATE. <br /> EHD Inspector: ece i flee <br /> UST SERVICE REQUEST INSPECTION REPOR i <br /> EHD 23-04 <br /> Rev 11/17/iOR <br />