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ul <br /> SAN JOAQUIN COUNTY <br /> 0: `yX ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Ins ction Date: <br /> LIJUM <br /> Facility Address: Service Request#: <br /> I U Ltf t 6 YO G?j G <br /> Onsite ervice Technician's Name: ICC Service echnici n/Installer Exp.Date: Manufact rer Train• g. <br /> SERVICE SERVICE <br /> Leak detector Sp l bucket minimum 5 gallon <br /> ❑ ❑ mechanical Model: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: v- Will st ❑ O er <br /> ❑ line test programmed al well S <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ 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 <br /> ❑ positive shutdown Model: ElPrimarpS piping testing at: <br /> El <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) hi f7 <br /> ❑ NA ti <br /> sensor Testing fo the above components are n t dine. y: <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 /> p tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> HO —Overfill <br /> Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> prevention (see LG letter 150-1) ❑ Other: see below <br /> 8 <br /> e <br /> II � f <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDIS CURRENT HOURLY RATE. <br /> EHD ctor: Receive B : " Title: LL <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />