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o.¢4u I�••.c <br /> E� P SAN JOAQUIN COUNTY <br /> G ENVIRONMENTAL HEALTH DEPARTMENT <br /> H'�y.IIII'' L <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> c4�iFo"ac'P <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspec ion Date <br /> S­ 2 t0 <br /> Facility Address: Servicb Request#: <br /> X3115 S. f-, O/-A/)0 Sk, , �reAC�x 4Anp S126b(o 9i6 <br /> Onsite Service Technician's Name: ICC Servic Technician Installer Exp. Date: Manufacturer Training: <br /> ell 6 M;r?2 Z r3 (� \) (= 21 , <br /> 10 <br /> SERVICE SERVICE <br /> Leak detector <br /> 1:1 mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial ElEl1 hour hydrostatic F] Incon TS-STS <br /> El line test programmed <br /> El Caldwell System 11 Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ 11 electronic Serial ElEl1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> Ll mechanical Model: Spill bucket 1-1 minimum 5 gallon <br /> F-1 ❑ electronic Serial : ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> CI line test programmed <br /> ❑ Caldwell System El Other <br /> sensor <br /> El positive shutdown Model: Primary piping testing at: <br /> El El psi <br /> El fail safe Serial #: <br /> El 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 2c 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) ❑ Other: see below <br /> �` e.r1 rD rproS^ a MDNi gje, L <br /> N owor!� S �s Q� -S ►tifr� <br /> VC,44 {- e 1 etk ri ill. r- VN on Pk u7 l i <br /> Vc4A <br /> ` y�14 <br /> 'e �vlr 1/l� y""� �b�^'► <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO AT ANY I E AT END'S CURRENT HOURLY RATE <br /> EH Inspector: eceive By: Title: <br /> U o►J �_o r\� <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />