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opg4!A'...c <br /> '' �` ''• ` SAN JOAQUIN COUNTY <br /> 2: .-ter.—,- •.y <br /> a' ENVIRONMENTAL HEALTH DEPARTMENT <br /> h. 600 East Main Street, Stockton, CA 95202-3029 <br /> P• Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> 4<1koaN: <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El El mechanical Model: ❑ <br /> El1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: <br /> Ll line test programmed LICaldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El electronic hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial <br /> ❑ line test programmed EICaldwell System ❑ Other <br /> _Leak detector Spill bucket E3 minimum 5 gallon <br /> ❑ I-] mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: 171 Caldwell System EI Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ _psi <br /> Ll fail safe Serial #: <br /> 11 NA minutes <br /> sensor ry Secondacontainment testing for: <br /> El ❑ positive shutdown Model: `� UDC(s) I'o,t'1 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 20 containment components are required to be tested upon <br /> ❑ NA instauaton,s months after,and every 36 months theneaaer. <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 /> I 1p <br /> I ` <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIM AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector.` 'R11cet ed�y � Title: <br /> �1 <br /> 2 <br /> ev 11/1l 7 7///08 \ , UST SERVICE REQUEST INSPECTION REPORT <br /> ev ---- <br />