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ACLU I <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> X <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s*clov.orq/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: <br /> Service Request#: <br /> 4 <br /> Onsite Service Technician's Name: [CC Service Technician/installer E Date: Manufacturer Training: <br /> 1 11 ),/ , ,/ -A <br /> t <br /> ILI' <br /> IA <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El El mechanical Model: El El 1 hour hydrostatic El Incon TS-STS <br /> 0 electronic Serial: <br /> 0 line test 0 Caldwell System El Other <br /> programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> D 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: El Caldwell System El Other <br /> El line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El 0 mechanical Model: El 0 1 hour hydrostatic E] Incon TS-STS <br /> El electronic Serial#: 0 Caldwell System El Other <br /> El line test programmed <br /> sensor <br /> - Primary piping testing at: <br /> 11 positive shutdown Model: <br /> El z 0 fail safe Serial#: psiminutes <br /> DNA <br /> sensor Secondary containment testing for:, <br /> F_1 Piping <br /> El positive shutdown Model: UDC(s) <br /> 0 fail safe Serial#: Sump(s) LIST(s) <br /> 0 NA <br /> sensor b Testing for the above components are next due by: <br /> 0 positive shutdown Model: <br /> D El fail safe Serial#: Note Please be aware that 21 containment components are required to be tested upon <br /> 0 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% El Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) El Other: see below <br /> N <br /> i P4C <br /> A <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> rEHD-1n,spector: I zRelzbived By: <br /> 03-04 UST SERVICE REQUEST INSPECTION REPORT <br /> 1/171/08 <br />