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ip <br /> SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Te%phone:(209)468-3420 Fax.(209)468-3433 Web:www,si-Qov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: <br /> VVI spection Date: <br /> Facility Address: [� <br /> Service/'� ` <br /> meq uesz;F: <br /> onsite semi ce Technician N me;� ICC service Technician/Installer Exp.Date: ManufactureWaining <br /> btr 1 (QST <br /> SERVICE SERVICE <br /> _Leak detector <br /> ❑ ❑ mechanical Model: _Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> _Leak detector <br /> ❑ ❑ mechanical Model: _Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> _Leak detector <br /> ❑ ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ fail safe Serial#: ❑ _psi <br /> ❑ NA _minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC <br /> ❑fail safe Serial#: (s) Piping <br /> ❑ NA Sump(s) UST(s) <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: <br /> ❑ NA Note: Please be aware that 2°containment components are required to be tested upon <br /> Installation,6 months after,and every 36 months thereafter. <br /> L <br /> Drop tube with mechanical overfill at 95% Cold start 5below <br /> ng panelDrop tube with mechanical overfillat 95% ❑ Corrosion Overfill prevention (see LG letter 150-1) ❑ Other: see <br /> le �o . A. <br /> '9 L—LE. <br /> NA'rM4 <br /> 46, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins o Receiy y: Title: <br /> cczL,. <br /> EHD 23-04 <br /> Rev 11/17//08 UST SERVICE REQUEST INSPECTION REPORT <br />