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SAN JOAQUIN 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.sioov.org/ehd <br /> ,[IFOQN` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Dat <br /> Facility Address: service Request#: <br /> n CAM roY g93?o <br /> Onsite service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> -50 Pen n 52Fo 3 Cg`1—(,I—f 613oLti Y1_ + *7-67SZ I <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El El mechanical Model: El 111 hour hydrostatic El Incon TS-STS <br /> F1 electronic Serial #: El Caldwell System L1 Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket 71 minimum 5 gallon <br /> ❑ mechanical Model: El El1 hour hydrostatic El Incon TS-STS <br /> 11 electronic Serial #: <br /> 171 line test programmed ElCaldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El ❑ 1 hour hydrostatic 1-1InconTS-STS <br /> El electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El positive shutdown Model:❑ psi <br /> ❑ fail safe Serial #: ❑ <br /> El NA minutes <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: Please be aware that 2°containment 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 goyte pad . <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Other: see below <br /> ©E s <br /> N%jR2Z 4m A a <br /> Row "Jpwa <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY ME AT EHD'S CURRENT HOURLY RATE. <br /> EHDI e or: Recelv y: I Title:C u � <br /> LL . <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />