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oA'•au I�••.o <br /> ': ®G SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> T Telephone:(209)468-3420 Fan:(209)468-3433 Web:www.si Oq v.or /g ehd <br /> UNDERGROUNDT (UST) PROGRAM SERVICEINSPECTION <br /> Facility Name: Inspection Date: <br /> Alf 71t- <br /> Oct <br /> Facility Address: Service a uest <br /> Onsite S rvice Technician's Name: ICC Service Technician/Installer Exp.Delta: Man acturer Training: <br /> - s 5 � t I <br /> SERVICE SERVICE <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 /> 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 /> 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 /> ❑ ❑ positive shutdown Model: El _psi <br /> ❑ fail safe Serialminutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ® ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fail safe Serial#: Sump(s) UST(s) <br /> 0 NA 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 /> P <br /> A,t Ips ` <br /> 6 <br /> THIS "TYIS TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD l a ctor: Recgivecl By: Title: <br /> LHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//09 <br /> 1 <br />