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� ot'Qul� • <br /> SAKI JOAQUIN COUNTY � <br /> • —rtr �i <br /> ENVIRONMENTAL F`IEALTFI DEPARTMENT <br /> .; '• 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(249)468-3420 Fax:(209)468-3433 Web:www.sigov,or 1/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> FL`s M6 J 61!9104? <br /> Facility Address: Service Request#: <br /> 15-61 JAal- NE � S/toos-tts 6 <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Trainin <br /> SZS DO Sr u 1 z�r�, Aa�m�'rK rvra� vomer � <br /> l�Tit us� 13 2 p �� �. � � / ;o <br /> SERVICE SERVICE <br /> Leak detector <br /> mechanical Model: Spill bucket El minimum 5 gallon <br /> F1 ❑ mechmechelectranic Serial#: ❑ El1 hour hydrostatic 11 Incon TS-STS <br /> El line test programmed <br /> 11 Caldwell System ❑ 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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ fine test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary contta'r r: �tS6GfIJ6 <br /> ElG,❑ positive shutdown Model. Att 2IJ s Piping <br /> ❑fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA 5dsensor Testin far he above components are next due by: <br /> El positive shutdown Model: 12 0e <br /> I IF <br /> ❑fail safe Serial#: Nole: Please be aware that 21 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) El Other: see below <br /> 2V wzA, 9--of-1td kzd <br /> wiq <br /> THIS FACILITY IS SUBJECT TO REINSPECTi N AT ANY TIME AT EH 'S CUR ENT HOURLY RATE. <br /> EHD Inspector: n Received By: Title: <br /> M ' <br /> EHD 23-04 LIST SERVICE REQUEST INSPECTION REPORT <br /> Rev 17117!!08 <br />