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?• —+E�''•o� SAN JOAQUIN COUNTY <br /> ~r�Y ENVIRONMENTAL HEALTH DEPARTMENT <br /> N: •{ <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Y. <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sogov.org/ehd <br /> S�%FpR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Na j, Inspection Date: <br /> Y� V <br /> Facilit Address: Se fc Re ues #: <br /> M U� !aas� <br /> On 'e Service T hnician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> E3 : ElEl❑ 1 hour hydrostatic Incon TS-STS <br /> ❑ electronic Serial: <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor <br /> positive shutdown Model: ❑ Primarppiping testing at: <br /> El El <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 /> El 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 /> l.� <br /> 3 P I I <br /> IOU <br /> - 1 5 ) q - I <br /> '5por & D t: <br /> HIS IS SUBJ CT O REINSP N T AN TIME AT END'S C RRENT HOURLY RATE. <br /> R ved y: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//0$ <br />