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OQ'gU I N. C • <br /> ?••'•-•E�''•p 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.org/ehd <br /> �'• �P <br /> q�iFoa� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Ft M 6/5/09 <br /> Facility Address: Service Request#: <br /> 15b J i�azf nj E S t2oo s-ilt-sS6 <br /> Onsite Service Technician's Name: [cc Service Technician/Installer Exp.Date: Manufacturer Trainin : <br /> U,s� 132 0 K� sZ5 0o S Z u i Wifi AD�m�%N ly o`�c' v �o <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> ❑ positive shutdown Model: PrimarpS piping testing at: <br /> El El <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary con�t�a� t��, p,i fDr. t/E <br /> El positive shutdown Model: �f,� (TUI-rdloC s /(L Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA � <br /> sensor Testin for he above components are next due by: <br /> El El positive shutdown Model: 2 <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 /> Z� U,,4 — nti At 4-z4 � <br /> THIS FACILITY IS SUBJECT TO REINSPECTI N AT ANYTIME AT EH 'S CUR ENT HOURLY RATE. <br /> EHD Inspector: /n w _ Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />