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SAN JOAQUIN COUNTY . <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> X 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orq/ehd <br /> 4�%FORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 4-/-- 10 <br /> Facility Address: Service Request#: <br /> -33575 k-,f�,�-- /ZL�59 I <br /> Onsite Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: ✓, gr /, <br /> O'er L.2Ii 0z <br /> SERVICE SERVICE <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 <br /> Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El <br /> ❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed 7Z ❑ Caldwell System ❑ Other <br /> sensor <br /> El positive shutdown Model: ElPrimarps piping testing at: <br /> ❑ fail safe Serial#: <br /> 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) ro Other: see below <br /> 10 IiJC L, 541ll /11 •e L'r <br /> HIS FAC ITY IS SUBJECT TO REINSPECTION AT TIMfjT EHD'S CURRENT HOURLY RATE. <br /> EH D sp t Received By Title: <br /> It ( G LK <br /> EHD 2304 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />