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CLU.I. <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0: X <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siaov.org/ehd <br /> 0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name:1- Inspection ate: <br /> 1-4 6 <br /> C44 <br /> s to(o71dze Sha-& t fl <br /> Facility Address: Service Request#: <br /> 3?9!5� 1,61, 69,1WIlIl /Q54 -/-?x <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> VP 111-aflo &Lw6kr <br /> kw 14 ho & <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 11 minimum 5 gallon <br /> 0 mechanical Model: - <br /> D F-1 0 electronic Serial #: 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 line test programmed 0 Caldwell System 0 Other <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> 0 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 0 mechanical Model: ❑ 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial#: 0 Caldwell System El Other <br /> Q line test programmed <br /> MsensorPrimary piping testing at: <br /> positive shutdown Model: D psi <br /> Rlail safe Serial #: ❑ <br /> minutes <br /> INN*&Vwro-r-� <br /> aeamdreau Secondary containment testing for: <br /> 'ail <br /> ositive shutdown Cos 100 UDC(s) Piping <br /> safe Serial#: Sump(s) UST(s) <br /> sensor ❑ 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 2*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% 0 Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) El Other: see below <br /> VOY)f r ty 0- PeA,4,�2� f 12- <br /> UZ7 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe Title: <br /> :!7;�� <br /> CT <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />