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OP�u�N'•.0 <br /> SAN aJOAQUIN COUNTY <br /> er ENVIRONMENTAL HEALTH DEPARTMENT <br /> W <br /> . < 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.si-ov.org/ehd <br /> cgCikoR�vP <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> � h11 - () 1 <br /> Facility Address: Servic4 Request#: <br /> 1 ' <br /> Onsite Service Technician's Name: ICC Service T hnician/Installer Eidp. Date: Manufacturer Training: <br /> ' 2 nI <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial: El El hour hydrostatic 1:1 Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ <br /> El electronic Serial: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El electronic Serial: El 1 hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor50,W Primary piping testing at: <br /> ❑ positive shutdown M el: ❑ psi <br /> ❑ fail safe Serial #: G minutes <br /> El NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Surril 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) [E] Other: see below <br /> [ n / � <br /> 4-1 ff-41 -RAY _ ` A odAfm <br /> <ienw6 = CA U <br /> THIS FACILITY IS SUBJECT TO REINSPEC N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In t r: Re d B Title: <br /> G <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />