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OP'•�u I N••.0 <br /> SAN JOAQUIN COUNTY <br /> 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 /> 4�l FORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name- Inspection Date: <br /> C h2VW S Q0.- T-A Aja rd Zc)1 b <br /> Facility Address: Service Request#: <br /> 3'�4 W L-k o a 59 ©o,Sq :7-3 <br /> Onsite Service Technician's Name � t ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> ZMVI <br /> ile <br /> PCG Z3/zol 1 %u tt.11,,� Z <br /> SERVICE SERVICE A24-&.3:Na Z <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: ❑ El hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ModeSpill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ <br /> El electronic : El 1 hour hydrostatic ❑ Incon TS-STS <br /> [I line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: El 1 hour hydrostatic ❑ Incon TS-STS <br /> [I line test ro rammed El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑fail safe Serial #: minutes <br /> ❑ NA <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 5$ <br /> 11 <br /> CV /v <br /> C <br /> 6 r i r. SL4 I' -5 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspectpr: / ��`/� R ceiv Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />