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a��s''•.o� � SAN JOAQUIN COUNTY <br /> =r fir. <br /> n t< 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 /> d�ikoa�'� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> OG - - o <br /> Facility Address: Service Request#: <br /> Z11-0yo <br /> Onsite Service Technician's Name: ICC Service Technician/Installer rr Exp.Date: Manufacturer Training: <br /> JL� <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 Oth <br /> ❑ line test programmed <br /> y / er Co-r2�i,� <br /> Leak detector Spill bucket ❑ minimum 5 gall n <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 /> ElElpositive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial #: Sump(s) UST(s) <br /> ❑ NA ❑ <br /> sensor Testing for the above components are next due by: <br /> El ❑ 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 <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI E AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receive / Title: <br /> EHD 23-04 V UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />