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ot'gu l�••c <br /> ? ' o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433Web:www.sigov.org/ehd <br /> dCrF®a`' <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspect' ate: <br /> Facility Addre : Service ques : <br /> C-z 14b [ e <br /> osv <br /> Onsite Service Technician's Ic cia Installer Exp.Date: Manu r t aini4 <br /> 7- <br /> SERVICE SERVICE <br /> ,WLjWLeak detector Spill bucket NGninimum 5 gallon <br /> mechanical Model: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <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 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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <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 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 LIS letter 150-1) Other: see below C-Ij;44n <br /> 0 i <br /> Al P <br /> �® l <br /> � O <br /> THIS FACILITY IS SUBJECT TO REINSPE A ANY TME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I ector: I Re lv B Title: <br /> `, <br /> EHD 23-04 • UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />