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¢quth <br /> SAN JOAQUIN COUNTY <br /> e: 1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> �.ki xI <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> C;.. �+r <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.orglehd <br /> gCIFro ft <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Elate: <br /> *6V,(4 P 420, M'4 119___ '_01 <br /> Facility Address: Service Request#: <br /> 9)D 'C'. 0051-t6 f <br /> On ijuieehnician"s Name: ICC Service Technicianllnstaller Exp. Date: Manufacturer Training: <br /> i�r�j �L�i 4 �5 ~UY c� �0 VrZ 3n�a�� 81� I&4v <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket Ll minimum 5 gallon <br /> ❑ El El❑ electronic Serial #: 1 hour hydrostatic 71Incon TS-STS <br /> El Caldwell System ❑ Other <br /> LJ line test programmed <br /> Leak detector Spill bucket Ll minimum 5 gallon <br /> ❑ <br /> [I mechanical Madel: EJ El1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test ro rammed <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 ❑ psi <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 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% TAJ Cold start of monitoring panel 1`5M ID/12� <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1} ❑ Other: see below <br /> 00 16 kb Wi <br /> E <br /> i a � <br /> THIS FACILITY IS SUBJECT TO REINSPEC ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: 1_ni d By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17 0 8 <br />