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o.Pa`'''I N•.c <br /> SAN.JOAQUIN COUNTY <br /> 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 /> q,C�FORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> (q to, (f-0 il�_i/_ <br /> Facility Address: Service Request#: <br /> ?/I Z I' �� �� '3 U Z, <br /> Onsite Service Technician's Name: IC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> Eeo&:= !V�. l� -� jele l z� g v <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket 11 minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> [I mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial : El [11 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> Ll mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> Ll electronic Serial : F-1 ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed <br /> Ll Caldwell System El Other <br /> sensor <br /> El positive shutdown Model: F-1 <br /> Primary testing at: <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <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 /> El <br /> y:❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note. Please be aware 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) ❑ I Other: see below <br /> 922f2; c- <br /> D►-- 4 4—k X45 4- wA 5 <br /> 2 b� <br /> THIS FACILIT IS SUBJECTTb REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect Received By: Title: <br /> IL <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />