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oAqutN .o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y. < 600 East Main Street, Stockton, CA 95202-3029 <br /> P Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> 9�/FORS` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Ar(c Ai,�i Co 7/i <br /> Facility Address: Service Request#: <br /> =r s s 14 <br /> Onsite Service Technician's Name: I C Service Technician/Installer Exp.Date: Ma;r2-Z0'z:7 <br /> r Training: <br /> E ��. � zS a vii q��J,r <br /> SERVICE SERVICE <br /> Leak detector <br /> K-mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> P5ElEl1 hour hydrostatic ElIncon TS-STS <br /> Elelectronic Serial #: 0106 122'L <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> ❑ ElElpositive shutdown Model: PrimarpS piping 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 /> ❑ ❑ 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 W CJR /Cows <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receive y: Title;_ <br /> le <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />