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?qulN 'o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y. _ 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Au A17)-Pn) voc Dr- <br /> Facility Address: y Service Request#: <br /> ys <br /> Onsite Service Technician's Name: ICC Service Techn'cian/Installer 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 <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> E] ❑ electronic Serial: ElEl1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Prin3Qry piping testing at: l <br /> El psi Z❑ positive shutdown Model: 0 pl <br /> El fail safe Serial #: t7r5w <br /> ❑ NA —W—minutes <br /> 60 S <br /> sensor Secondary containment testing for: <br /> ElElpositive shutdown Model: r UDC(s) 0 Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA p <br /> sensor Testing for�helIto&L'co p <br /> onents are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please 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 /> tm AJ( i G, <br /> o i <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO T ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I ector: R ived B Titles <br /> =ZL�—�z lan? <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11117//08 <br />