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op4utN c <br /> ?•'��'••�� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y. 600 East Main Street, Stockton, CA 95202-3029 . <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> 4�/FORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Na f Insq ti n i T V 01 <br /> e <br /> Facility Address: Service Request#: <br /> Lt b LAJ C(,,,or�eA, IvA,--( 3/2 00 S >0 2 !e <br /> Onsite Service Technician's Name: ICC ervi Technician/Installer Exp.Date: Manufacturer Training- <br /> a <br /> v�c• S�0 8 l 1( _ /� J <br /> v <br /> SERVICE S R ICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ El hour hydrostatic ElIncon TS-STS <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 /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> [I mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: El L11 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> El El shutdown Model: ElPrimarppiping testing at: <br /> ❑ 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 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) ❑ Other: see below <br /> IVv ,'A lel ( �✓` <br /> THIS FACILITY IS SUBJECT TO REINS TIOAT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD nspector: R c Ived Title: <br /> w sJ 2 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />