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°vaulry. <br /> ?•''-�'�'''•p SAN.IOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.or /q ehd <br /> 4�/PORE <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspect'on Dae: <br /> N4 C (do -7(, (g4j f4tin Z 11 11 U . <br /> Facility Address: I Service Request#: <br /> Z S- -? UvN G Ja Qucl . i S4bGl,6�-O �oZ <br /> Onsite Service Technician's Name: ICC S rvice Technician/Installer Exp. Date: ManufacturerTraining•] <br /> IAN <br /> 4' �� <br /> SERVICE SERVICE <br /> Leak detector <br /> 11 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: El El hour hydrostatic ElIncon 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 /> El ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El 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 /> 1,7 sensorPrimary piping testing at: <br /> `positive shutdown Model. �� �K ❑ psi <br /> Kfail safe Serial #: minutes , <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> positive shutdown Model \m UDC(s) Piping <br /> fail safe Serial #: Sump(s) 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) ❑ Other: see below <br /> W/116 41 )A C_ 0-121 t!!�) 7T /V a ba-� �e Arn ,-r <br /> (Jt s-��d�< en �E <br /> an OeLtn re /1'of I <br /> THIS FACILITY IS SUBJECT TO REINSPEC 10 Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins ector: Re v Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />