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oaq�I N••.c <br /> SAN JOAQUIN COUNTY <br /> a' y ENVIRONMENTAL HEALTH DEPARTMENT <br /> y..bu �'. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.slaov.org/ehd <br /> 4��FpR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: I Inspection Date: <br /> AP 06( )Onao— q• ID . D <br /> Facility Address: Service Request#: <br /> ",�vi� � V*�W 5F—W9_10�00 <br /> IR. nsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> WA <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial :: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> [_1 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> F-1 ❑ electronic Serial : ❑ El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> L1 mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial: El El hour hydrostatic El Incon TS-STS <br /> 71 line test ro ra med El Caldwell System El Other <br /> NI ns <br /> j ❑ sitive shutdown Model: V A Primary piping testing at: <br /> I't )fail safe Serial #: '](, Z2 ❑ psi <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 months thereafter. <br /> ❑ j 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 /> Q w �-- <br /> THIS ACILIT IS SUBJE INSPECTION AT Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> E I r: Received By: Title: <br /> U_At7l< 77e,��e/f -t f c e <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11117//08 <br />