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OR`Q u 1. •.0 <br /> SAN JOAQUIN COUNTY <br /> y� 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��FOKd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: _ Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Ex Date: Manufa rer Training: -6-14,1 <br /> LL�-a vr F,5�, (-I C-1!4L <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ <br /> El electronic Serial: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System 11 Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ lin test ro rammed ❑ Caldwell System El Other <br /> 01 sensor <br /> V-po itive shutdown Model: 2f0 Primary piping testing at: <br /> 11 psi <br /> EI fail safe Serial #: - <br /> ❑ NA minutes <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. 11 <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 /> C j411iaf �IJ <br /> !? ��Yi � 'C u htC-�( ���'�.@_ ,vISD►'s �1 L�-- l' �- SP CM� C ��5� <br /> rill L, A'j1 D 'A" "72 Pro& -fv by tl- m, k iN4� <br /> THIS FACILITY IS tUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CUR NT HOURL RATE. <br /> EHD Inspector: � e Titl , <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />