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®�qu eN•c <br /> ?'' ® SAN JOAQUIN COUNTY <br /> ZA ENVIRONMENTAL HEALTH DEPARTMENT <br /> e 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone.(209)468-3420 Fax:(209)468-3433Web:www.siaov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICEREQUEST IN <br /> SPECTION REPORT <br /> Facility Name: In ection Date: <br /> 1i �%L U 166�L <br /> Facility Address: I Service Request : <br /> I <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> I=u CLb <br /> X, 420 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 9 minimum 5 gallon <br /> ® ❑ mechanical Model: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System El Other <br /> El line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System [I Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El positive shutdown Model: <br /> El ❑ fail safe Serial#: ® psi <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 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 /> 06 #,N%� +ofj;m oP hletA A caka�c. loik 2k&1,j6h� A d 'rc&A� <br /> .. ► U ��1 <br /> i1� u Lu 4- <br /> cv�s6ek Sc <br /> THIS FACILITY IS SUBJECT TO REINSPECTION hNY TIME T 'S CURRENT H ULY RATE <br /> EHD Ins pe or: Re 'ved By: Ti e: — <br /> 1�® 'e, 61 . <br /> ('r6b, <br /> EHD 23-04 ERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />