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O.P''4u(N'•.0 <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.org/ehd <br /> '9C/F ORt� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: ti Inspection Date: <br /> VCd1ky V" 2=01 <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: g <br /> 52 <br /> %k I� `g0.4k d 1 'W 1'2A14� -- UT 6 l3 i� 1� J Je Z u . 3'''►°" 1/15/z'w <br /> SERVICE SERVICE <br /> Leak detector <br /> [I mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: E] El1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: ❑ El hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> [I mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> 1:1 Caldwell System ❑ Other <br /> sensor <br /> 1:1 El positive shutdown Model: Ell <br /> Primary testing at: <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <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: 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 4 � '� � �� <br /> ❑ Drop tube with mechanical overfill at 95% El Corrosion protection ° Z 5i1y •61 <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> el ra - 111711- l� f a AH D ) i I , f es <br /> c <br /> THIS FACILITY IS SU JECT TO REINSPECTION AT ANY TIME AT EHD'S CURREN HOU LY RA E. <br /> EHD Inspector: Received By: -� Title: ZJZT rJ <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />