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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> tet. •X <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web: o�v.or /�ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> -SP411 n N <br /> vd <br /> Onsite Service Technician's Name. ICC Pervic Technicilifi-/��p. Date: Manufacturer Traininp: <br /> V <br /> A ollgeq Dou) <br /> M -Cj- �� _ :2/p/to <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El 0 mechanical Model: 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell SystemO ther <br /> 0 line test programmed X <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> F-1 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial: <br /> 0 line test 0 Caldwell System 0 Other <br /> programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El 0 mechanical Model: ❑ 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial: <br /> 0 Caldwell System 0 Other <br /> 0 line test programmed <br /> sensor Primary piping testing at: <br /> El El psi 0 positive shutdown Model: <br /> 0 fail safe Serial#: minutes <br /> 0 NA <br /> sensor Secondary containment testing for: <br /> El 0 positive shutdown Model: UDC(s) Piping <br /> El fail safe Serial #: Sump(s) LIST(s) <br /> El NA sensor ED Testing for the above components are next due by: <br /> El El positive shutdown Model: <br /> El fail safe Serial#: Note: Please be aware that 2*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% El Cold start of monitoring panel <br /> El Drop tube with mechanical overfill at 95% Corrosion protection 1*11-� <br /> El Overfill prevention (see LG letter 150-1) j I El I Other: see below <br /> THIS FACILIjXkS SUBJECT TO REINSPESTIOV AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I�A�ctor: ol" Re elf Eh: Tit& <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />