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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Y. <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> 0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> --f <br /> Fb ��j 2-Z-/o <br /> Facility Address: Service Request#: <br /> 1!Z 3 aNE Alp6tj -W-06sqsn <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> 1771 0 mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial: <br /> El Caldwell System El Other <br /> 0 line test programmed <br /> Leak detector - - Spill bucket 0 minimum 5 gallon <br /> ❑ 0 mechanical Model: F 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System 0 Other <br /> 0 line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El 0 mechanical Model: El 0 1 hour hydrostatic El Incon TS-STS <br /> 0 electronic Serial: <br /> El Caldwell System El Other <br /> El line test programmed <br /> -----sensor Primary piping testing at: <br /> El 0 positive shutdown Model: ❑ psi <br /> 0 fail safe Serial #: minutes <br /> 0 NA <br /> - sensor Secondary containment testing for: <br /> El 0 positive shutdown Model: UDC(s) Piping <br /> 0 fail safe Serial #: Sump(s) UST(s) <br /> 0 NA sensor ❑ Testing for the above components are next due by: <br /> E] 0 positive shutdown Model: <br /> 0 fail safe Serial #: Note: Please be aware that 21 containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> ❑ —Drop tube with mechanical overfill at 95% F71 Cold start of monitoring panel <br /> D Drop tube with mechanical overfill at 95% El Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) Other: see below <br /> b 10^10111 oda��� AA" ---Leg, ce/Kx=a� <br /> P? 1 '01 b5 lfo,Ltn6-- �c mvwDtj <br /> ,4MA041AA--" oia.,A . f7 <br /> 'THIS FACILITY IS SUBJECT TO REINSPEC*ON'"ANY TIME AT EHWS CURRENT HOURLY'RATE. <br /> AJ <br /> EHD Inspector: ReceiV I By: Title: <br /> EHD 23-04 S<j LIST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />