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OP''�u I,N,• C <br /> SAN JOAQUIN COUNTY <br /> e' Za ENVIRONMENTAL HEALTH DEPARTMENT <br /> ;; 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 4�/FOK� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> l e l 1Ye-WW_b. Gig— Moo" 5(Z6&;?0v 3 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> R46A,J',N ( CL#: 523 5; <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ <br /> El electronic Serial: El El hour hydrostatic El Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ❑ 111 hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> positive shutdown Model: ElPrimarppiping testing at: <br /> El El❑ fail safe Serial #: p <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) f 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 /> Jl►,c_ ,�SiG�,G� � f�c( ft..� ail <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TWE AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received B Title <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />