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0 <br /> got' u' ''c® SAN JOAQUIN COUNTY <br /> 'a 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 /> UNDERGROUND <br /> STORAGE TANK ( T) PROGRAM SERVICET INSPECTION <br /> Facili Name: Inspection Date: <br /> *Uzi 2TOP <br /> Fa i ity d ess: 6I S - e es ' <br /> 8 <br /> nsite S rvice Tec nician's Na C rvice TecVid,�iilinsYallerExfpe: <br /> Manu cturer raining: p <br /> I/ <br /> SERVICE SERVICE <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 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 Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial : ❑ Caldwell System ❑ Other <br /> ❑ linpjqst programmed <br /> sensor Primary piping testing at: <br /> r <br /> hutdown Model: ® psi <br /> Serial#: minutes <br /> sen Secondary containment test' r <br /> El positive shut own 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) ❑ Other: see below <br /> t ` <br /> 1 ' <br /> t c <br /> P <br /> I FACILITYI ABJECT T REINSPECTION T TI ATE T Y RATE. <br /> R ive <br /> fp ';0 t <br /> EHD _ ` S VICE REQUEST INSPECTION REPORT <br /> Rev 11/1 108 <br />