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otquiy c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone.(209)468-3420 Fax.(209)468-3433Web:www.sl og v.or_ /c�ehd <br /> UNDERGROUNDT T (UST) PROGRAM SERVICET INSPECTION REPORT <br /> Facility Name//: Inspection Date: <br /> Facility Address: Service Request M <br /> 12. 5P'0®5761 <br /> nsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Lee, V- p��tis3 <br /> 12n <br /> Y., c <br /> SERVICEVICE <br /> Leak detector 13 <br /> ❑ mechanical Model: Spill bucket minimum 5 gallon <br /> ❑ ❑ electronic Serial ,01 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> � <br /> El mechanical Model: Spill bucket minimum 5 gallon <br /> El ❑ electronic Serial hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: ► <br /> Spill bucket minimum 5 gallon <br /> ❑ El electronic Serial #: ,b1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> tatAe 6 sensor <br /> positive shutdown Model: ZD Primary piping testing at: <br /> fail safe Serial #: El psi <br /> ❑ NA minutes <br /> t-'sensor Secondary containment testing for: <br /> ru positive shutdown Model: UDC(s) Piping <br /> ail safe Serial#: "'7,iW -A icd Sump(s) FA?—!V,AO&Z UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ positive shutdown Model: 71 <br /> ❑fail safe Serial #: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> F❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% El Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> u. acS F��✓ ws +r+ I/t G f? <br /> •L�►..� HhC�e.-. r 7nG e... S (rim 5 S <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI IE AT D'S CURRENT HOURLY RATE. <br /> EHD Inspecto I Re 'vea By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />