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A <br /> ot'aU9 it <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.siaov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> t rsjoe( <br /> Facility Address: Service Request#: <br /> (L <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> L- <br /> 5 15;4-15 LA i Aw"xim <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> ❑ 0 mechanical Model: El El 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial: <br /> 0 line test El Caldwell System 0 Other <br /> programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> E] : <br /> mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System 0 Other <br /> El line test programmed I <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El <br /> 0 mechanical Model: F❑ 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial <br /> 0 line test rorammed El Caldwell System 0 Other <br /> pg <br /> sensor Primary piping testing at: <br /> El 0 positive shutdown Model: Els <br /> 0 fail safe Serial#: minutes <br /> 0 NA <br /> - sensor Secondary containment testing for: <br /> 0 positive shutdown Model: UDC(s) b,,L <br /> E] , - f2e�� Piping <br /> 0 fail safe Serial #: S Sumps) UST(s) <br /> El NA <br /> sensor Testing for the above components are next due by: <br /> ❑ 0 positive shutdown Model: <br /> 11 fail safe Serial #: Note: Please be aware that 21 containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> El Drop tube with mechanical overfill at 95% 1:1 Cold start of monitoring panel <br /> D Drop tube with mechanical overfill at 95% El Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) El Other: see below <br /> -ota—� 4-eAf V–V—VA <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: ed B Title: <br /> SL <br /> V <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/171/08 <br />