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gctu I <br /> SAN JOAQUIN COUNTY <br /> X <br /> H <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> K, <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siaov.org/ehd <br /> 4cik0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> -no I <br /> Pc 12-CID MOP 491 Z.-T 169 <br /> Facility Address: Service Request#: <br /> Ta Tr" 00 5 -339 <br /> Onsite Service Technician's Name: [cc Service Technician/installer Exp.Date: Manufacturer Training. <br /> o-,' <br /> D 022q7,,3—V–r ILS012 VK Pb 17-20 L7 L3 <br /> T— <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial 0 Caldwell System El Other <br /> 0 line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial: <br /> 0 line test rogrammed <br /> 0 Caldwell System 0 Other <br /> p <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El 0 mechanical Model: 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial ❑ <br /> 0 line test rogrammed 0 Caldwell System 0 Other <br /> p -- <br /> 2-6 sensor in 5-7 Sqr%p M45kX Primary piping testing at: <br /> Xpositive shutdown Model: /W- 97,14 El psi <br /> )<fail safe Serial <br /> 0 NA k*V=W-- minutes <br /> z 20 5:11Z <br /> - sensor Secondary containment testing for: <br /> El 0 positive shutdown Model: UDC(s) Piping <br /> 0 fail safe Serial #: Sump(s) UST(s) <br /> 0 NA sensor Testing for the above components are next due by: <br /> ❑ El positive shutdown Model: <br /> 0 fail safe Serial #: Note: Please be aware that 21 containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> F-I Drop tube with mechanical overfill at 95% E] Corrosion protection <br /> 0 Overfill prevention (see LG letter 150-1) El Other: see below <br /> rllY�Llj AM Vie, <br /> Ttl$ZACI �!j IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In Received By: Title: <br /> 401-t)V\ <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />