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SAN JOAQUIN COUNTY <br /> ar■■..��, Z� ENVIRONMENTAL HEALTH DEPARTMENT <br /> y'. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.slgov.org/ehd <br /> A�/FOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Pio Jah 0 2v <br /> Facility Addres . Service Request#: <br /> 3k--1 D N'6r�- �I , Tau. 04 6 nO2. <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Mainufacturpr Training: <br /> Y11�S IQPSPO� <br /> � CJ-),6044WUT 0(-(6-,t l "ft <br /> G5-02-1 I <br /> SERVICE SERVICE <br /> Leak detector <br /> 1:1 mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ❑ El hour hydrostatic 1:1Incon 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 11 Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> sensor TV, <br /> i ry piping testing at: <br /> El El <br /> positive shutdown Model: <br /> Elfail safe Serial#: psi <br /> El NA �minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: 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 /> -12bU 4s� 3 q <br /> THIS FACILITY IS SUBJECT TO REINSPEC ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD InspRctoj Rec <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />