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ActuIN <br /> SAN JOAQUIN COUNTY 46 <br /> Q' Za 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.orq/ehd <br /> ORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Servilbe Request#: <br /> O%,41b G), i/�,A-h St) 7-ra4Y <br /> Onsite Service Technician's Name: ICC Se ' e Te hnicia /Installer Exp. Date: Manufacturer Training: <br /> � <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket 11 minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> 11 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System E] Other <br /> Leak detector <br /> El mechanical Model: Spill bucket 11 minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> ❑ El psi <br /> ❑ fail safe Serial#: <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 ❑ 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 /> t <br /> D <br /> THIS FACILITY ISS ECT TOR PECTION NY T E AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />