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CL UV I <br /> 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.sigov.org/ehd <br /> 4LlF0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility N Inspection Date: <br /> �� 1 1-% MAJ 115 as C� l000 C <br /> Facility Address: Service Request#: <br /> r—Onsite service Technician's Name: TService Technician/Instaftr Exp.Date: Manufacturer Training:EC— () 1 6i j/ - <br /> V <br /> A SERVICE SERVICE <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> echanical Mod 1: L 061&0 <br /> 0 electronic Serial #: El Ei 1 ❑hour hydrostatic El Incon TS-STS <br /> El line test programmed 0 Caldwell System 0 Other <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial #: 0 Caldwell System El Other <br /> 0 line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El El mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial: <br /> El line test rorammed 0 Caldwell System 0 Other <br /> pg <br /> sensor Primary piping testing at: <br /> 0 positive shutdown Model: El psi <br /> El fail safe Serial#: <br /> 0 NA minutes <br /> sensor Secondary containment testing for: <br /> El 0 positive shutdown Model: UDC(s) Piping <br /> 0 fail safe Serial #: Sump(s) UST(s) <br /> 0 NA sensor El Testing for the above components are next due by: <br /> El 0 positive shutdown Model: <br /> 0 fail safe Serial #: Note: Please be aware that 21 containment components are required to be tested upon <br /> 1:1 NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% El Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) El Other: see below <br /> 10 -r—O r <br /> I <br /> o4 bl4A <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT 4NY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspectpr: Recerid By: Title: <br /> I <br /> ? <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br /> "j <br />