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N _ - <br /> eQpu1N C111111 <br /> � .®�.�_ • .o� - SAN JOAQUIN COUNTY <br /> a 2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> "= 600 East Main Street, Stockton , CA 95202-3029 <br /> • �• Telephone: (209) 468-3420 Fax: (209) 468-3433 Webs wwwsigov. org/ehd <br /> 9�IFOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: _ Inspection Date: <br /> cw ,atery <br /> 1 l - ( t) - 2e?, z <br /> Facility Address: Service Request #: <br /> [0 L lb ` o <br /> Onsite Service Technician's Name: IC • Service Tec nician/Installer Exp. Date: Manufacturer Training: <br /> AAA <br /> II <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El11mechanical Madel: El 1 hour hydrostatic [I Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector _ Spill bucket Ll minimum 5 gallon <br /> ElElmechanical 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 /> El fail safe Serial #: _ minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ElElitive s <br /> poshutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial #: Sump(s) UST(s) <br /> ❑ NA ❑ <br /> sensor Testing for the above components are next due by: <br /> [E] El positive shutdown Model: <br /> El fail safe Serial #: Note: Please be aware that2° containment components are required lobe tested upon <br /> installation, 6 months after, and every 36 months thereafter. <br /> El NA <br /> _ Drop tube with mechanical overfill at 95% ElCold 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 /> ❑ This UST facility is APPROVED to operate ❑ This UST facility Is NOT APPROVED to operate <br /> Sn f 1 Yi C. yv. & tr20 $ n� S <br /> j `h [ 7Y ` Usl l t <br /> ell A- <br /> T 1k�iC fell. ' f1v Its iVt ) Y . <br /> THIS FACILITY IS SUBJECT TEREINESPECTIt ,.TfAT EH 'S CURRENT HOURLY RATE. <br /> ns ct r: e' _ Title: <br /> UST SERVICE REQUEST INSPECTION REPORT <br /> EHD 23-04 <br />