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opa`'Ik' <br /> ?•''��''•p SAN JOAQUIN COUNTY <br /> y; ?x ENVIRONMENTAL HEALTH DEPARTMENT <br /> '. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.orcl/ehd <br /> �q�IFOiRt�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Insp/TV :Z" i Ait� ection D e: <br /> , <br /> oll <br /> Facility Address:I Service Req est#: <br /> Onsite ServiceTechnician's N me: ICC Service Technician/Installer xp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> 11 mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <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 /> sensor <br /> ❑ ❑ positive shutdown Model: ElPrimarps piping testing at: <br /> ❑ fail safe Serial #: <br /> ❑ NA minutes <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 20 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 /> I Z N I'fo <br /> 1/1 41 -0- EC v- 7 <br /> THIS FACILITY IS SUBJ CT TO REINSPINTJQAT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I ctor: Re a y: Title: <br /> D �I3 �� �I t ti �T/1 STSE� REQUEST INSPECTION REPORT <br /> EH 1 / � �Ve <br /> Rev 11/17//08 <br />