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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.s' ov. / hhd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fadilb�►Name: ! Inspection Date: <br /> N a <br /> 5,01 to 0 <br /> Facigty AWrem: Ser <br /> �r � vice R t 0: <br /> S> D ��� Li- <br /> Qns16e!larvlce hniclan'e Name: ICC Service TechnidjIlVindefler Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <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 /> Leek detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑milid nical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 0 electronic Serial#: ❑Caldwell System ❑ Other <br /> ❑line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑poeltive shutdown Model: 15psi Ql A AA <br /> ❑fall safe Serial#: _L.(2minutes <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: Ptaase be awnn uw r awaaira"amponw+a an►eq*W to be uftd upon <br /> ❑NA mW WO n,6 monft~,ane every 36 menthe theraarter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ 1 Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overbill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other. see below <br /> � SSS <br /> i) r ma ma , I -n,,g.- <br /> r <br /> THIS FACILITY IS SUBJE T TO REINSPECTION AlANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD 1 Re By Title: <br /> :!y <br /> EHD 23-01 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 1 111 7/10 8 <br />