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°'P4uty 'O•o 1i SAN JOAQUIN COUNTY 1-.r/ <br /> a•�t .o <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> �'r�rFORN`~ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Na Inspection Date: <br /> A (� <br /> FaAddress: se t es <br /> cility <br /> - u1 !7 Requ) <br /> On ' e Service Tef hnician's Name: ICC Service Technician/installer Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ED El❑ electronic Serial #: 1 hour hydrostatic El Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El 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 /> El positive shutdown Model: <br /> El ❑ fail safe Serial #: ❑ msnutes <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 /> ElE) positive shutdown Model: <br /> ❑ fall safe Serial #: Note Please be aware that 2^contamrrwnt componems are rewrw to be tested upon <br /> ❑ NA mstallabon,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 /> Q -7 <br /> MAIl lP <br /> S I 2 3 P I F5— <br /> II � <br /> fiawle 5 <br /> Il`HIS IS SUBJ CT O REINSP N TAN TIME Ri Y RATE. <br /> E In r. R ved y: Title: <br /> EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/1'//08 U <br />