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ot'aU l�••c <br /> ?' ® SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> • ;� Telephone:(209)468-3420 Fax:(209)468-3433Web:www.sigov.or /g ehd <br /> UNDERGROUND T TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: n All InspectionpPate: <br /> Facility Address:/� >,, Service Request#: <br /> dj��/ — <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Tr ining: <br /> o <br /> SERVICE SERVICE <br /> Leak detector <br /> F-1 mechanical Model: Spill bucket El 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 Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ 111 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:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> /� sensor <br /> positive shutdown Model: Primary piping testing at: <br /> El psi <br /> ❑ fail safe Serial#: <br /> ❑ 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% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LIS letter 150-1) ❑ Other: see below <br /> /�ozrjler 71-0 01177t- 122 co <br /> f <br /> A <br /> THIS FACILITY I JECT TO REINSPECTI Y TIME AT EHDS CURRENT HOURLY RATE. <br /> EHD Inspector: Re ' ed Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />