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a•�t••.oc 9 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 /> 'f�I F 0'R�`• <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> CT 55' (OI /:7 /o <br /> Facility Address: Service Request#: <br /> O D 5 ley r -5l2,:;)o 6/016 <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller 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 /> 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 /> ❑ ❑ positive shutdown Model: ❑ _psi <br /> ❑fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) 5-Ai Piping <br /> ❑fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> _sensor Test' for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note: Pleese De 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 <br /> ❑ _Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> J21; <br /> I IF <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD !nspe Received By: Title: t/ <br /> �L( <br /> EHQ 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11117//0 <br />