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oPq'utN c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> t <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> . P Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.siclov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 27 1V-d i�Gi/ ��J l9 /o <br /> Facility A ss: Service Request#: <br /> Onsite Service Technician's Namb,.' ICC Service Techniciannnstaller Exp.Date: Manufacturer Training: <br /> LLl '12 al 0 2 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 2/minimum 5 gallon <br /> El El Model: hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial El 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> E] NA minutes <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 /> 97�,_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 /> 5G' <br /> 7�-X-7(-&ttyP -A <br /> f19 oz4h,?. ,47 <br /> or <br /> �br <br /> THIS FACIL Y UB ECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT OURLY RATE. <br /> EHD In Received By: Titl <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/171/08 <br />