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a'���'•pc " SAN JOAQUIN COUNTY <br /> ee. 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 /> d[ikoPt': <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: .}-�� Inspection Date: <br /> t� <br /> Facility Address: Service Request#: <br /> 325 0 + LA del b JIL 9 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer raining: <br /> VM I v e S <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: [I El hour hydrostatic ❑ Incon TS-STS <br /> EI electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ El mechanical Model: El 1111 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ElCaldwell System ❑ Other <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El 1-1 <br /> mechanical Model: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> 1-1 electronic Serial #: EI Caldwell System 1-1Other❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> ❑ ❑ fail safe Serial #: Elp si <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial M 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 awme that 20 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 /> `M <br /> G pA5Ge E4 gcA- t-PP r <br /> to U. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURREN HOURLY RATE. <br /> EHD Ins a Received Title: <br /> ro <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 111171/08 <br />