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V! c <br /> SAN JOAQUIN COUNTY <br /> e y-+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433Web:www.sigov.org/ehd <br /> ®R��P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE T INSPECTION REPORT <br /> Facility Name: Inspection Date- <br /> Facility Addr s: 0service Request#: <br /> Onsite Service Technician's Name: ICC Service Te nician/Installer Exp.Date: f4anufacturer raining: ' <br /> Ckead ,evoy- <jA(0 Tb1� "vim I2/I71704o /y1 2 1 <br /> r • <br /> VICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> FEl ❑ electronic Serial:: ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial:: ❑ El hour hydrostatic El Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> F-1 ❑ electronic Serial:: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primaps piping testing at: <br /> El 11 <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 20 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 /> d <br /> - 5-� e o <br /> OL44 1 ' <br /> I <br /> THIS FACILITY IS SqBJECT TO REIWS0EcftjbN AT ANY TIME T EH 'S CURRENT HOURLY RATE. <br /> EHD Inspe r cei By: Title: <br /> 15S94,C-e- <br /> EHID <br /> 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />