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oR+Qul"/• c <br /> SAN JOAQUIN COUNTY <br /> $< ENVIRONMENTAL HEALTH DEPARTMENT <br /> Y. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> •v�,F®tea <br /> UNDERGROUND T TAN (UST) PROGRAM SERVICEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> FN W Ot I G(201 '0,9 <br /> Facility Address: Service Request#: <br /> 15-N T60 6 O N `s fz�54 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE VICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: [0] El1 hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor ' <br /> ❑ positive shutdown Model: ElPrimarpsping testing at: <br /> F-1 <br /> ❑ fail safe Serial : minutes <br /> ❑ NA <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 LG letter 150-1) fA Other: see below <br /> C AA <br /> i T" 00�(-Z!l�j t"3 � ®• Kph S <br /> 112 <br /> (L �l RC- Q Igo <br /> THIS FACILITY IS SUBJECTITO REINSPESTIg <br /> &AT ANY TIME T ' CURkENT HOURLY RATE. <br /> .tpl7ft <br /> EHD Inspector: Rete' ed Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />