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�. �,,,�•�'`c �. SAN JOAOUIN GQU <br /> r.' ;= '; <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 600 East Main Street, Stockton, CA 95202-3029 k. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siQov.or ft,feehpi 3 2 i <br /> SAP <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST IN PORT <br /> Facility Frame: ' lr T Inspection Date: <br /> ~_ _ =^,•1 . `t�`' i2rE:tile ;�("7'" �i� ��'. , �i,;! <br /> Facility Address: Service Request ft <br /> Onsite Service Technicians Name: ICC Service Techniciantlnstaier Exp.Date: IMlanufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector z <br /> ❑ mechanical Model: ?.Al Spill bucket 19 minimum 5 gallon <br /> ❑ ❑electronic Serial# t).1 hour hydrostatic ❑Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> 171 ❑mechanical Madel: ❑ ❑ 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: p ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial ❑ Caldwell System ❑ Other <br /> ❑ line test Proorammed <br /> sensor Primary piping testing at <br /> ® ❑ positive shutdown Model'. ❑ psi <br /> ❑fail safe Serial A minutes <br /> ❑ NA <br /> - sensor Secondary containment testing for: <br /> ❑ ❑positive shutdown Model: UDC(s) Piping <br /> 0 fail safe Serial# Sump(s) UST(s) <br /> L0 NA ; <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑positive shutdown Model: <br /> ❑fail safe Serial#: We: Please be aware tdat 2"containment components we required to t:e tested upon <br /> ❑ IIIA instaltallon 6 mantles atter,and every 36 months ttiereette•. <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 /> t <br /> . <br /> t is r s:e• <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspeettsr. Receiv•ov' r Title;, v— <br /> �_, ,�f f. �,/ + _\.f•ti's- ,t,- y�, <br /> EHO 23-64 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11 M MOS <br /> l,'d <br />