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�qulN . <br /> �o.E�.coG SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Do <br /> ld 12,1 uI <br /> Facility Address: Service Request#: <br /> G3o Yas l Sk00-7675 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Da P Manufacturer Training: vYo,�, <br /> Wl It lGG 90 66 u T '►I V 337 9 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial El El hour hydrostatic ElIncon TS-STS <br /> [I line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> positive shutdown Model: ❑ Primary ppiping testing at: <br /> El El❑ fail safe Serial #: p <br /> El 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 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% <br /> MIA <br /> Cold start of monitoring panel U/Z U <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> rEITOverfill prevention (see LG letter 150-1) ❑ Other: see below <br /> 60U S4114 A22e P-"W� <br /> G <br /> A� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION fij ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re ived Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />