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®R+Qu IK•.c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> rA. <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ;P® Telephone.(209)468-3420 Fax,(209)468-3433Web:www.sj og v.org/ehd <br /> dcs ®ate <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICEUST INSPECTION REPORT <br /> Facility ame: Inspection Date: <br /> Facility Addre : S rvice Request#: <br /> N9 :2&- <br /> W -ITOV ek 'gkolk)' - <br /> Onsite Service Technic' n's .ame: ICC rvice TechniciaNlnstaller x Date: Manufacturer Trai ng:' <br /> SERVICE11-� <br /> 7 <br /> 2--2 s:V-q,4-L(,-M <br /> I E <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> M <br /> ctronic Serial ❑ ❑ 1 hour hydrostatic E] Incon TS-STS <br /> line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ echanical Model: Spill bucket ❑ minimum 5 gallon <br /> El electronic Serial#: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 1 14 ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <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 /> ❑ ❑ 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 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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME T EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: R ived By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />