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�o.• c® SAN JOAQUIN COUNTY <br /> �.• :err-. '•.cy <br /> �. ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Y. <br /> Telephone:(209)468-3420 Fax:(209)468-3433Web:www.siaov.org/ehd <br /> gctF®R"' <br /> UNDERGROUND STORAGET (UST) PROGRAM SERVICEEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 15- <br /> ,r7) <br /> K..'Doct a <br /> Facility Address: Service Request : <br /> 161 L-4nlam.- 5a OQs(>7 4K 4+ <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICEVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El : El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial: <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: 9/ Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial ❑ 1 hour hydrostatic 1:1 Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> Mode �} Spill bucket ❑ minimum 5 gallon <br /> F-1 ❑ electronic El mechanical Model: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ 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 21 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 /> i°i''G <br /> no e p 1.-- <br /> Cjw. <br /> ga IJ <br /> G �1 <br /> T S FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME ATE D'S CURRENT HOURLY RATE. <br /> EHD In ect Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17// 8 <br />