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7T <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 F&K. (209)468-3433 Web:www.SiQOV.O[g/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fad ft flame: Inspection Date: <br /> lk- '4- -r v e o t-z S- 13— 2d l <br /> FaciNly Service Request*: <br /> S 00- <br /> �015-0 5L [) <br /> Technician's Name: ICC Service TechyiciaMnstaller Exp.Date: Manufacturer raining: <br /> r <br /> SERVICE SERVICE <br /> Leak detectorSpill bucket ❑ minimum 5 gallon <br /> ❑ 0 mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: Q Caldwell System D 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 porammed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: ❑ Caldwell System D Other <br /> ❑line test programmed <br /> leggk sensorPrimary piping testing at: <br /> Gpositive shutdown el: ❑ psi <br /> ❑fail safe Serial#: minutes <br /> U.NA <br /> ensor t�.b Secondary containment testing far. <br /> ❑positive shutdown Model: `T' 8 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#: Hot.: PMeea be awes pru r oomrirrmwt components re rogvW to be t..ud upon <br /> ❑NA hWjedM B mm**ager.r,d wry 36 months a,.rs~ <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) 4Other: see below <br /> ..� 0. <br /> d AA <br /> Go L,5 a$jj& <br /> bbs410'6e& 2) s -Aq / a�Cbc su <br /> THIS FA ILITY IS SU ECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY TE. <br /> EHD t <br /> 9e. d• Jf}`�� <br /> ( N <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 1 111 7110 8 <br />