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tAW ty <br /> ` -� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> P Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.siclov.orglehd <br /> 4t1 FORK <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Name: Inspectio" Date- <br /> 1410 <br /> ate- <br /> 10 <br /> Facility Address: Service Request#: <br /> FIn 0M <br /> Onsite Service Technician's Name: -Service Tech nicianllnstaIler 9xp.Date: Trai no' <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical MadelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: LlF] 1 hour hydrostatic 71Incon TS-STS <br /> ❑ line test ro rammed 17Caldwell System ❑ Other <br /> Leak detector <br /> Model: Spill bucket L1 minimum 5 gallon <br /> mechanical <br /> ❑ <br /> LJ electronic ModeSerial ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> F1 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial #: ❑ LJ1 hour hydrostatic C1 Incon TS-STS <br /> El line test programmed <br /> Ll Caldwell System El Other <br /> sensor <br /> ❑ positive shutdown Model Primary piping testing at: <br /> p gr <br /> ❑ fail safe Serial #: --' <br /> El NA nutes <br /> ft <br /> sensor Secondary containment testing for: Y'f <br /> positive shutdown Model: UDC(s)pl h f� Pip <br /> El El positive ng <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: Piease be aware that 21'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 /> 4 3 ,k <br /> 3 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION/AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins a tor: Re 've B . Title: <br /> A A A A�:J � /_? &U=�, __jr <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11117//08 <br />