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SAN JOAQUIN COUNTY <br /> G ENVIRONMENTAL HEALTH DEPARTMENT <br /> N: < <br /> ;. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> �A«F OtR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Namr Inspegti �Rate; _ <br /> 1 S U <br /> Facility Add Service Request#: <br /> O site Service Tehmc 'Is Name: ICC Service Tech i /installer Exp.Date: M nufacturer Training: <br /> f 112, <br /> . n 1,11ORM <br /> dl��) <br /> zat <br /> SERVICE S t RVI E <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: vi� ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> [electronic Serial#: 1 ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector ( / j I Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial#: ,��) <br /> ❑ •ne test programmed <br /> ❑ Caldwell System ❑ Other <br /> I <br /> Aeak detector ( Spill bucket ❑ minimum 5 gallon <br /> mel anical Model: Y ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial#: 1 ❑ Caldwell System ❑ Other <br /> / ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ pos ive shutdown Model: UDC(s) Piping <br /> Cliail safe Serial#: Sump(s) UST(s) <br /> A ❑ <br /> sensor Testing for the above components 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 /> t <br /> .� <br /> IF <br /> THI§YACILI7, IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> H91 s e A R=By:VV <br /> ! .� <br /> E H D 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/1 7//08 <br />