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a �i'•.p L SAN JOAQUIN COUNTY <br /> �� yy ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 600 East Main Street, Stockton, CA 95202-3029 <br /> P. Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sioov.or!alehd <br /> G%FOPS\ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> C4 CA 3/((,/ 1/ <br /> Facility A dre : Service Request#: <br /> S �/(GtM C� <br /> site Service echnician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> SCSa� <br /> SERVICE SERVICE <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: <br /> El ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ 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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ p <br /> si <br /> ❑fall safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fall 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 20 containment components are required to be tested upon <br /> ❑ NA nstallation,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) 54 Other: see below <br /> d o C woa <br /> s S ( <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector. ReceivedlEy ``L Title: <br /> EHD 23-04 �`• UST SERVICE REQUEST INSPECTION REPORT <br /> Rev l l/17/108 <br />