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SAN JOAQUIN COUNTY <br /> Gy ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ . 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 9�� pada <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facili Name: Inspection Date: <br /> Facility Address: �r Service Re uest#: <br /> --77Q2 <br /> Onsite Service Technician's Name: ICC Service Techniclan/lnstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <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 /> 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 /> 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 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 /> ❑ NAElsensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑fall safe Serial#: Nate: Please be aware that 20 containment components are required to be tested upon <br /> © NA instMetion,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 /> F � 9"1 N�-� "rh-�" 1G-fti,--!'{" .� r_� ._�,r �r•5 jC<F f "�f^f= �✓i 5,�r'. �,�1 <br /> l <br /> . t <br /> THIS FACILITY IS SUBJECT TO REIN ECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD�A o' / Receiv,,d By: Title: �� , <br /> V I t # 1— rj <br /> EHO 23-CO UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17/108 <br />