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RgUV I <br /> SAN JOAQUIN COUNTY <br /> c. 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 /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service RequestIM <br /> Onsite Service Technici 's Name: ICC Service Technician/I staller E Date: Manufacturer Traini <br /> der ����1 �� �f GO lla <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: <br /> F1 El electronic <br /> bucket ❑ minimum 5 gallon <br /> electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ElEl1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor y piping testing at: 11�� <br /> El ❑ positive shutdown Model:❑ fail safe Serial #: — psi <br /> 1:1NA minutes S'tQ pjeli 66)A.r �s <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) &&&I Piping <br /> ❑ fail safe Serial #: Sump(s) f <br /> UST(s) <br /> ❑ NA <br /> sensor Testing for the ab ve 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 /> Ur I rr <br /> . (1'� h <br /> A4 ILPW <br /> THIS ACI ITY IS SUBJECT TO REINSP CTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I pector a ived By: Title: <br /> A <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />