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oaq`'''I N• c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> OR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> c t PrNay QNB u � N t/2-2, I o <br /> Facility Address: Service Request#: <br /> v D STWASPAJ 6kWJ 6 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> (� I2 GP tjV p Sz4$�163 -uT � z3( i( A2,3,1/C-'7 it <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: E] El1 hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> F-, ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> El El shutdown Model: ElPrimarppiping testing at: <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 /> -7 0 (P390- 7-09 44 l 1h P&Ad - W s c <br /> — Au, m or" ,,r <br /> tcr <br /> NU - D^j -- 'zo $0 ( q Z-7 `u+1�i�e�l/� <br /> THIS FACILITY IS SUBJECT TO REINS WTIRN AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: R i d Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />