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°Paula 'c SAN JOAQUIN COUNTY <br /> �.•Et •.off <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> e• •'a <br /> y.: 600 East Main Street, Stockton, CA 95202-3029 <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 /> FaciliName: Inspection Date: <br /> �19f G�%' g ( '�) 1 .1 . rI <br /> `FacilityAddress: - Service Request#Of� `[ L C <br /> gnpite Service Teconiciane: ICC,Service Tech nicianllnstaller Exp. ate: Mfacturer Traini g: <br /> 1 c� <br /> SERVICE SERVICE <br /> Leak detector <br /> 11 mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ d El1 our hydrostatic 11 Incon TS-STS <br /> ❑ electronic Serial #: ff ❑ Caldwell System El Other <br /> ❑ line test programmed <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 /> ❑ positive shutdown Model: �(,(!F�.f� / Primary Xpiping testing at: <br /> ❑ fail safe Serial #: Elpsi <br /> NA minutes <br /> Uuu�ensor Secondary containment test•n for: <br /> ❑ positive shutdown Model:_ UDC(s) 1901 Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> nsor 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 /> ❑ 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 LIS letter 150-1) ❑ Other: see below <br /> sL <br /> VILAW <br /> THIS FACILITY IStUBJECTVTO REIN PECTION AT NY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector ived B::LI Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />