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®�'qu1ly c <br /> . ®G SAN JOAQUIN COUNTY <br /> Z� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ` a�•® Telephone:(209)468-3420 Fax:(209)468-3433 e :www.sj og v.org/ehd <br /> R4%F®R� <br /> UNDERGROUND T TAN (UST) PROGRAM SERVICE ST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 11 <br /> 1 <br /> Facility Address: Service Request#: <br /> Ar <br /> a t o. I <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: ' Y, 7/ <br /> Oievlm)o Gu000 at. !E� 2 LDI 2)(-A <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model1 Spill bucket inimum 5 gallon <br /> El : ❑ 1 hour hydrostatic 11 Incon TS-STS <br /> ❑ electronic Serial: <br /> ❑ line test programmed Caldwell System ❑ Other <br /> Leak detector <br /> 11 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El❑ electronic Serial ❑ 1 hour hydrostatic I-] Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket 11 minimum 5 gallon <br /> El ❑ electronic Serial:: 1:10 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> Di <br /> El ❑ 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 I 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) ❑ Other: see below <br /> r Ae <br /> t <br /> THIS FACILITY IS SUBJECT TO REINSPECTION ATA Y TIME T EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receive Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />