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oR4ulN•c <br /> ?' oc SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .,y <br /> u) <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> �' • aP., Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND T TANK (UST) PROGRAM SERVICEUST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service <br /> 4C 11 Service Request#• <br /> 4 '51-�7 <br /> -6 2' a I lc ! M-i\ems- /1' <br /> Onsite Service Technici 's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> O <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ElElpositive shutdown Model: p <br /> si <br /> ❑fail safe Serial#: ❑ minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) 7 Piping <br /> ❑ fail safe Serial #: 974 21Sump(s) UST(s) <br /> ❑ NA <br /> sensor <br /> Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall 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 /> ° g=,= t r® <br /> df�,(�.,.�- 1 -tis -_ I �.�.►�-. <br /> All 4-s s sftf <br /> THIS FACILIT IS SUBJ CT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Ins or: R Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />