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o.P441N <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> rm < <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> �4�iFoat'vP <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.siaov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Da e: <br /> -4 - ill-ekA (0730 /2do " <br /> Facility Address: rr Service Request#: <br /> , III e OA n �YI LO <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <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 programmed ❑ Caldwell System ❑ Other <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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El El <br /> mechanical Model: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: <br /> El line test programmed ElCaldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑fall safe Serial #: <br /> ❑ NA _minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) 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 2-containment components are required to be tested upon <br /> ❑ NA Installation,6 months after,and every 36 nnnths 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 WA ( UZ Roa <br /> 2v V i S o r, W1 C <br /> -. <br /> AA <br /> o SEI' cQ <br /> r .11614�fkulA -1,Q44 <br /> via PA4& <br /> li Q I oY <br /> THIIt AN IME AT EHD'S CU RENT HOURLY RATE. <br /> EHD Insp> Received By: Title: <br /> &2a ULM <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />