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?°' ®G SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 4 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.siaov.org/ehd <br /> 9C%P®FR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date:vvm <br /> Ck <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> F-1 : El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial: <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: E] ❑ 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor <br /> El positive shutdown Model: 11Primaps piping testing at: <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 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 pane ° e <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection CA to Ca <br /> ❑ Overfill prevention (see LG letter 150-1) 5L Other: see below <br /> / t . 0 <br /> r ,. f� P <br /> Sd�S a�S c a" <br /> -f �. Sol <br /> I �"v s �' <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EH 'S CURRENT HOURLY RATE. <br /> EHD Ins c ed By Title <br /> v <br /> EHD 23-04Gf UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />