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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0: X <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433Web:www.sigov.org/ehd <br /> aclF®R`' <br /> STORAGEUNDERGROUND (UST) PROGRAM SERVICEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> tosis-021 <br /> Facility Address: Servicd Request#: <br /> ® �1 N s m 6 <br /> rC6o0j(r1j <br /> Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: .:r IX01 2 -' U i 3 - 53 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial : a ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> El positive shutdown Model: E] Primarps piping testing at: <br /> ❑ fail safe Serial #: p <br /> ❑ 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 21 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 /> / - <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME T H 'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By Title: <br /> EHD 2M4 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />