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o?'� I'!. a ♦� <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 /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name:&�T604 <br /> f� Inspecti n lte: <br /> !! z- <br /> Facility Address: Servibili Request#: <br /> Onsite Service Technician's Name: ICC Servic Technician/installer Exp. ate: Manufacturer Training: <br /> �6 �- `�'la ( Vit-} - �, I� VI& 6?�0 19S,2�_ <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model:: ElElElSpill bucket El minimum 5 gallon <br /> ❑ electronic Serial1 hour hydrostatic Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> 111 electronic Serial. ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> sensor +M Ulm >3r, <br /> positive shutdown Model: Il3 Primary piping testing at: <br /> El psi <br /> fail safe Serial #: <br /> ❑ NA <br /> minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> El fail safe Serial #: Sump(s) UST(s) <br /> El 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 contairmert 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 /> THIS FA ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHInspe r clued y: Title: <br /> r/✓Jr <br /> I T1 <br /> El 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />