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_:• ham .. „cZ SAN JOAQUIN COUNTY <br /> -+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 'X 600 East Main Street, Stockton, CA 95202-3029 <br /> �' aP•® Telephone:(209)468-3420 Fax:(209)468-3433Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Nam•::L Inspection Date: <br /> C" I CA ' 1 og <br /> Facility Address: S rvice Request#: <br /> 1570.1 ,'R A C-17 f Cao 5Tq cS (, <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date 'Maw to r T ibitlg: <br /> 'Y v <br /> SER <br /> VICE SERYICE <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 2Wgrammed <br /> sensor Primary piping testing at: <br /> tA sitive shutdown Model: "7`14-3l�'0®?-09 El psi <br /> Fail <br /> safe Serial #: 7614.42 minutes <br /> A <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) LIST(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 2°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 /> C-1/9 w- <br /> d M Crlp� <br /> HIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME T EHDIS C'URREP4 HOURLY RATE. <br /> EHD Inspector: Re ' ed By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />