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ogaul c <br /> ? ® SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ..'rt...- `P.® Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 4�/F®Re' <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Addres : j Servi Request#: <br /> Onsite Service Technician's Name: Service Technician/Installer Exp.Date: Manufacturer Training: <br /> VA B360`34-0-/9- <br /> VICE SERVICE <br /> -Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ® ❑ electronic Serial: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> sensorf <br /> (�positive shutdown Model: Primary piping testing at: <br /> ❑fail safe Serial#: El psi <br /> 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 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 /> /P <br /> IGr P <br /> rveTce M21 <br /> f'- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT H 'S CURRENT HOURLY RATE. <br /> EHD Insp or: Re ive By' Title: <br /> EHD 23-04 U UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />