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oP4�ty. <br /> SAN JOAQUIN COUNTY �r <br /> ra 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 /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facili Address: Se ice Request ii: <br /> W. �� ��` I f)60C-7/u# <br /> Onsite Servic Technician's Name: ICC Servi I Techn g/Installer Exp. Date: Manufacturer Training: ��ee�� r� T <br /> / / W I/ l.Wl <br /> SERVICE SERVICE <br /> Leak detector Spill bucket LI minimum 5 gallon <br /> ❑ El mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System 1:3 Other <br /> El line test programmed <br /> Leak detector Spill bucket EI minimum 5 gallon <br /> El El mechanical Model: El El1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System EJ Other <br /> El line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: El ❑ 1 ho <br /> ❑ electronic Serial#: ur hydrostatic ❑ Incon TS-STS <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El ❑ positive shutdown Model: El psi <br /> ❑ fail safe Serial#: <br /> ❑ NA minutes <br /> sensor S condary ontainment testin for: <br /> ❑ ❑ positive shutdown Model: Z 3( UDC(s) Piping <br /> ❑fail safe Serial #: Sump(s) UST(S) <br /> ❑ NA <br /> sensor Te ting for the above components are next due by: <br /> El 11 <br /> positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 2-containment components are repulred to be tested upon <br /> ❑ NA Instatation.6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> F-1Droptube with mechanical overfill at 95% ❑ Corrosion protection <br /> E] Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> L 00 uq/ �✓ <br /> oftri, V V ' k <br /> 4recL., S S <br /> THIS FACIL Y IS SUBJECT TO REINSPECTION ATA Y TI A EHD'S CURRENT HOURLY RATE. <br /> E p ct cei ed Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 1111708 <br />