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• <br /> L' .•—car., .G <br /> SAN JOAOUIN COUNTY <br /> a; 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: Inspeion Date: <br /> �(io& 2 <br /> Facility.Address: <br /> Service Request#: <br /> OnsiVervice Technician's Name: ICC Service Te/chnJiciannllinnstaller Ex ./Date: M nufacturer Training: <br /> S 01 o tot �v�l l (�3 J <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial #: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <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: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> El positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> ❑ NA _minutes <br /> sensor Seconjdary containment tasting,fgrl <br /> El ❑ positive shutdown Model: UDC(s) /{ 11 Piping <br /> ❑ fall safe Serial #: <br /> ❑ NA Sump(s) � UST(s) <br /> sensor Testingv for the above c mponents are next due by: <br /> E] ❑ positiveshutdown Model !KS �� J�u:s - <br /> AppkA <br /> ❑ fail safe Serial#: Note: Please be aware that 2"containment components are required lioonaef� <br /> mttedu <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 /> 26 tic <br /> u� I,h dun <br /> 6kk °l D yr atf <br /> THYS F CILI IS SU JECT TO REINSP C A HD'S CURRENT HOURLY RATE. <br /> EH ns l d <br /> EHD 23-04 UST/SERVICE REQUESTr INSPECTION REPORT <br /> Rev 11/17//08 <br />