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qui <br /> �' c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N; < <br /> .._ '. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/e <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> D ` <br /> Facility Address: I Service Request#: <br /> —(; V-� SM) �6A <br /> 4 <br /> Onsite Si echnician's Name: cc Servi a Technician/Installer Exp.Date: Manufacturer Training: ' I <br /> 40) <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket F-1 minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed El Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> ElEl [I❑ 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 : ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial: <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor <br /> El El shutdown Model: ElPrimarppiping 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 20 containment components are required to be tested upon <br /> El 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 /> r ( wwar <br /> - <br /> ' S <br /> V/ S. <br /> r <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins pe Receiv By: Title: / <br /> EHD 23-04 UST SERVICE REQU ST INSPECTION REPORT <br /> Rev 11/17//08 <br />