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�' E SAN JOAQUIN COUNT`d' <br /> y� :< <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwW.sigov.orCj/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> FU'1/AJ6 T 10 n/09 <br /> Facility Address: Sqrvice Request#1: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: /Maar&ct� <br /> SERVICE SERVICE <br /> Leak detector <br /> MadeSpill bucket ❑ minimum 5 gallon <br /> El ❑electronic❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed Serial © Caldwell System F-1 Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> 11 mechanical Model: <br /> El ❑ electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> LJ line test programmed <br /> ❑ Caldwell System ❑ Outer <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test pWgrammed <br /> sensor Primary pipirtg testing at: <br /> sitive shutdown Model: ?`14- s ❑ psi <br /> fail l safe Serial#: 7614.32A Aminutes <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 Serial <br /> ❑fail safe #: Note: PEease 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 <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> LLr <br /> K <br /> u-►.� dA44 = 44 .20f <br /> HIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S &URREW HOURLY RATE. <br /> EHD Inspector: Re ' ed By: Title: <br /> io ' /0911>" — - U l4%% <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11117/108 <br />