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uv if <br /> SAN JOAQUIN COUNTY <br /> X ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.siaov.org/ehd <br /> 0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> ra4& 12j- Ll /W] <br /> Facility Address: Service Requesf#: ' <br /> I -sit 0 <br /> Onsite Seoice Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector 1?5;1– Spill bucket Xminimum 5 gallon <br /> • mechanical Model: <br /> ❑ 0 electronic Serial#: )KI hour hydrostatic 0 Incon TS-STS <br /> El Caldwell System Other 'VVA1111& <br /> El line test programmed <br /> V", <br /> Leak detector <br /> • mechanical Model: —Spill bucket 0 minimum 5 gallon <br /> ❑ F-1 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial#: <br /> El line test programmed 0 Caldwell System 0 Other <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> D 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 /> sensor Primary piping testing at: <br /> El 0 positive shutdown Model: 0 DS11 <br /> 0 fail safe Serial#: —minutes <br /> 0 NA <br /> sensor Secondary containment testing for: <br /> 0 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 0 positive shutdown Model: <br /> 0 fail safe Serial #: Note: Please be aware that 20 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 /> 0, _Drop tube with mechanical overfill at 95% El Corrosion protection <br /> [I Overfill prevention (see LG letter 150-1) LE-1 Other: see below <br /> oh-sikel r4i' ll wi/Ic—& 4eo "it 6A/Abt� AAAJ� ja(ve- WP <br /> re– W-44fv f)- M�0& & q el rq4>A4,+L4 0(– 3 `av qaAa/4- <br /> r <br /> 1676 z- 7, &' UL '93� -kij,6 -6'Yt [fAnAtti , liplucw- 066W <br /> kly±Lsb�DhL Lej& n1vain -&!jCtby10a W AA01 V&IaL <br /> C-�cc rkil tiA kcfi L��Q <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EH 'S CURRENT HOURLY RATE. <br /> EHD Inspecto R ived BY: Title <br /> A <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />