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� SAN JOAQUIN COUNTY r/ <br /> -ter ENVIRONMENTAL HEALTH DEPARTMENT <br /> c � <br /> m; < <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> �4Cileoa'�'�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Dai <br /> Facility Address: Service Req est#: <br /> o s112-a6s3- <br /> Onsite Service Technician's NgkmT. ICC Service Technicianllnstaller xp.Date: Manufacturer I mining: <br /> ✓ Cyt cs�� 252�tg k <br /> SERVICE SERVICE <br /> Leak detector Spill bucket E) minimum 5 gallon <br /> ❑ 11 mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> 1-1 line test programmed D Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El1 hour hydrostatic ❑ 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 D Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: ElPrimaryping testing at: <br /> D fail safe Serial #: psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> D 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 /> ❑ fall safe Serial #: Nate Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA installation,6 months after.and every 3 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ]EE1 <br /> 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 /> tell SS lklapii 69 <br /> z, l3-1 11lM�f <br /> Ccrville� �M, K� Ili . — c�su� h� fx �Cr%r.✓� �' <br /> THIS FACILITY IS SUBJ CT TO REINSPf PTJOAT ANY TIME AT EHD'S CURRENT HOURLY RATE. �4Lj <br /> EHD tor: Rec e y: Title: <br /> EH P /3 d-r ' - 11t4 A,%Is ^'�"' �iw US SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 V `/ <br /> 0.S s N 2a✓ LA M> d w ( G,�� f <br />