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ul� <br /> ?•'-+E�''•p SAN JOAQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> t 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 /> Facili e: Inspection Date: <br /> rV <br /> Facility Addres ,'We Request o/► ((f <br /> site$ervic echnician's Name: ICC ervice Technician/Installer Exp Date: �M ja ufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El 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 El Other <br /> sensor <br /> El positive shutdown Model: ElPrimarps piping testing at: <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 20 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 /> • <br /> v d Fit <br /> : 1 - 1 ti' i n <br /> f c' <br /> uL W N sem- icSS �e <br /> jffrD-Ln&kUh' I a-\. + Ceffelai <br /> THIS FACIL Y IS SUBJECT TO REINSPECTI NAT ANY TIME AT EHD'S CU RENT HOURLY RATE. <br /> EH Insp or: Re ed By Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17/!08 <br />