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oPqul Y SAN JOAQUIN COUNTY It <br /> `t ?� 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/e <br /> SC%FOR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Inspection Date: <br /> Facility NametTeennician-s <br /> Service Request#: <br /> Facility Addre 'S P-Ch�SK 4tc 1_ <br /> Onsite ServicName: ICC Serviee Technician/Installer Exp.Date: Manufacturer Training: <br /> � W aPL,/ X—If 11 <br /> SERVICE Fhydrostatic <br /> ERVICE <br /> _Leak detector cs Iet �9 minimum 5 gallon <br /> ❑ ❑ mechanical Model: �1 htatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caem ❑ Other <br /> ❑ line test programmed <br /> _Leak detector _ ket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 tatic ❑ Incon TS-STS❑ electronic Serial#: ❑ Catem ❑ Other <br /> TODline test ro rammed <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> echanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ectronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test ro rammed <br /> sensor Primary piping testing at: <br /> ositive shutdown Model: ❑ _psi <br /> all safe Serial#: minutes <br /> DNA <br /> sensor Secondary containment testing for: <br /> ❑ positive shutdown Model: UDC(s) Piping <br /> ElSerialfall safe Serial #: Sump(s) UST(s) <br /> ❑ NA ❑ Testing for the above components are next due by: <br /> sensor <br /> ❑ ❑ positive shutdown Model: <br /> ❑fail safe Seflal #: Note: Please be aware that2 Wn ainment components are requiretl to be tested upon <br /> installation,6 months after,and every 36 months thereafter. <br /> LO Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> prevention (see LG letter 150-1) ❑ Other: see below <br /> L .. P <br /> v / STC'rYc_ <br /> � a SL <br /> lrX� p l/ II <br /> Ga W�I�ls o I r �I�?Y✓ 40o <br /> THIS FACILITY IS SUBJECT TO REINSPECTION T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHDlnspedo' <br /> R d By: Title: <br /> UST SERVICE REQUEST INSPECTION REPORT <br /> EHD 23-04 <br /> Rev 11/17//08 <br />