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aqu t 1V <br /> �o. •.co 0 <br /> SAN JOAQUIN COUNTY <br /> W. �� ENVIRONMENTAL HEALTH DEPARTMENT <br /> y ,r 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone.: (209)468-3420 Fax: (209)468-3433 Web:www,s'g6v.org/ehd <br /> 4 ?ko `' <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspe tion Date <br /> Facility Address: Servi a Reque t#: <br /> 27 _ n+r 01A qjuo. S US- 2 o <br /> Onsite Service Technician's Name: ICC Serle Tbchniciantinstaller Exp. Date: Manufact rer Tr ning: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket 171 minimum 5 gallon <br /> ❑ ❑ electronic Serial: ❑ LJ1 hour hydrostatic F] Incon TS-STS <br /> ❑ line test programmed <br /> LJ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model:: Spill bucket ❑ minimum 5 gallon <br /> 7-1 electronic Serial ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial : ❑ Ll1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> positive shutdown Model: Primary piping testing at: <br /> psi <br /> fail safe Serial #:p(�L? 1 minutes <br /> NkN A <br /> sensor Secondary containment testing for: <br /> Qpositive shutdown Model: UDC(s) Piping <br /> Mail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> El fall safe Serial #: Note: Please be aware that 2'containment componer s 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) X Other: see below <br /> U car UM ,-e, OfO &� <br /> P11 v r U 1 07 <br /> k - 0', V, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOU R -t"J, <br /> EH specter: f Received Title: <br /> T _ <br /> 1 1_4 t <br /> It <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/1 7110 8 <br />