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u l lv c <br /> ?• �F�'•pa SAN JOAQUIN COUNTY • <br /> -err. ENVIRONMENTAL HEALTH DEPARTMENT <br /> �a y< <br /> .. � 600 East Main Street, Stockton, CA 95202-3029 <br /> P Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjpov.orq/ehd <br /> q�%FORa` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> r 12- <br /> Facility Address: Service Request#: <br /> '5140 N. 64-d-' 7d <br /> Onsite Service Technician's me: ICC rvi echnicia Ex' ie: Manufacturer Training: <br /> �� ac -M Igo I I V,e I -7/10 <br /> SERVICE SERVICE <br /> Leak detector <br /> ModeSpill bucket El minimum 5 gallon <br /> El ❑ electronic El mechanical Model::Serial ElEl1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> ❑ 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 /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: ElEl1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor n ° �t Primary piping testing at: <br /> ositive shutdown Model: V "r� ❑ psi <br /> Mail 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 /> ❑ 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) ❑ 1 Other: see below <br /> V8ELP W1 r? — a I�-iv <br /> Ian f- L ss-ed <br /> on h SSP <br /> THIS FACILITY IS SUBJEC TO REINSPE TION T ANY TI AT EHD'S CURRENT HOURLNY RATE. <br /> bEHD I ector: Re ed Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />