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AquIN <br /> �o. .coG SAN JOAQUIN COUNTY <br /> Q a ENVIRONMENTAL HEALTH DEPARTMENT <br /> y `, 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siGov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectio at <br /> C %I &ZMAW It( p <br /> Facility Address: r Service Request#: <br /> -00 N. 081W., f� - <br /> OnTechnician's Name: ICC Service Technician/Installer Exp.Date: Manufactu r Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket Elminimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket 11 minimum 5 gallon <br /> F-1 : El 111 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial: <br /> ❑ I' st ro rammed El Caldwell System El Other <br /> ensor <br /> positive shutdown Model: Primary piping testing at: <br /> 11 fail safe Serial #: El psi <br /> El 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 F-1Testing for the above components are next due by: <br /> ❑ positive shutdown Model: — 46)? <br /> ❑fail safe Serial #: Note: Please be aware that 21 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 /> <l' 1� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD I e' ed By: Title:1 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />