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�P4uly <br /> �o.• __�` coG SAN JOAQUIN COUNTY <br /> Z ENVIRONMENTAL HEALTH DEPARTMENT <br /> �. `. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.orq/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> P�fGo AM PM d-4 - 10 <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/In t Iler Exp.Date: Manufacturer Training: <br /> s a o� 10 16zyg-jT ��, . o�2410 U>M r* 6311i <br /> blw, a <br /> SERVICE SERVICE <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> 10mechanical Model: a ❑ El 11 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electrcnic Serial* El Caldwell System ❑ Other <br /> El line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial: ❑ El hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> Ll Caldwell System El Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail szfe Serial#: minuies <br /> ❑ NA _ <br /> sensor Secondary containment testing for: <br /> ❑ ❑ pcsitive 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 P ease be aware that'°containment components are requ red 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 /> O Drop tube with mechanical overfill at 95% O Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Z' Other: see below lQQPW& 6Q 15VF" W""T G?D– <br /> -TO Ole,, 01 -fvr&�4 , Ail �' � �,�►� f �-�e a ►►�l� — <br /> Aek c,�- a (W,l(- � 3 aa.Qt nn U{naun. (Q <br /> r <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EH Q n pector. Receive y: ,• Titles <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 1111117808 <br />