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�Qul <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orq- /ehd <br /> .......... <br /> 0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite <br /> Service-Technician'si4ame: ICC Sirvice Technikin/installer Exp.Date: Manufacturer Training: P>1!0-4A d he, <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial: <br /> 0 line test El Caldwell System 0 Other <br /> programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> E] I-] mechanical Model: El El 1 hour hydrostatic El Incon TS-STS <br /> • electronic Serial: <br /> 0 Caldwell System El Other <br /> El line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> • electronic Serial: <br /> 0 Caldwell System 1:1 Other <br /> ­ . inqAwt programmed <br /> IRV IS UW sensor <br /> ositive shutdown Model: Primary piping testing at: <br /> 41Q�pEl psi <br /> 0 fail safe Serial#: minutes <br /> DNA <br /> - sensor Secondary containment testing for: <br /> ❑ 0 positive shutdown Model: UDC(s) Piping <br /> El fail safe Serial#: Sump(s) LIST(s) <br /> 0 NA sensor ❑ Testing for the above components are next due by: <br /> ❑ 0 positive shutdown Model: <br /> El fail safe Serial#: Note: Please be aware that 20 containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> 0 Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> El Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) F-1 Other: see below <br /> A <br /> V,o jc;�i J'L I At 6ev V-0-o("k <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspect r-. Received By: <br /> Inspect <br /> fnA <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />