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°aqulN. <br /> SAN JOAQUIN COUNTY <br /> e. ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.si4ov.orcl/ehd <br /> �4ClFOR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility.Nam Inspection Date: <br /> �)1 Pwkd(� 7111 - 61 <br /> Facil Addr Service Request#: <br /> a�11 �Wery <br /> , �� �r, 5 yam, <br /> Onsite Service Technician's Name: ICC Servic T chnician/Installer xp.Date: M ufacturer Training: <br /> Oe <br /> - )4-�) t "3 b 6q <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: ElEl1 hour hydrostatic 11Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: ElEl1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: ElEl1 hour hydrostatic El Incon TS-STS <br /> ❑ line est programmed <br /> El Caldwell System El Other <br /> ( sensor a / yv-' <br /> ❑ shutdown shutdown Model: ( iG( {'�Jy Primary piping testing at: <br /> El fail safe Serial#: + I? El Primary <br /> ❑ NA minutes <br /> WKI-WqV4 sensor '!� �S„'QD Secondary containment testing for: <br /> ❑ positive shutdown Model: v qq UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ����- S,(A ❑ Testing for the above components are next due by: <br /> ❑ positive shutdown Model <br /> ❑ fail safe Serial#: C -� rl, 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 LG letter 150-1) X Other: see below <br /> *WrA Vffb. Soy w v j� ;�AW � f;,.e 8-�-r--22 GTP <br /> `uLr 1 <br /> Vf <br /> THISFAf ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E DI rlsI Received Title: <br /> 1101, <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />