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°AautN '� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sogov.org/ehd <br /> jb— <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> C <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> ;-Y) PIN8114 ,52-50 01ZIll, �r �l StzvCt e �II z <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial: ❑ El hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket F-1 minimum 5 gallon <br /> ❑ <br /> El electronic Serial: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> F-1 ❑ electronic Serial: El 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> El El positive shutdown Model:sensor Pri aryAg testing at: <br /> si <br /> ❑ fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) brims-i Ijg4 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 Uvt "C4n.crr s <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> 5 -tD Lv n wv1 - - dumb &wa j k --G ( I-eKIAV, <br /> QjUIAZYJ <br /> �� va <br /> -)- ars <br /> ` I <br /> �- ` l P,,(- <br /> T IS FACILITY IS SUE1JECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I ector: Recei d By: Title: <br /> `ID 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> v 11/17//08 <br />