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tQX ug 1! <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> X <br /> Y:. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.s*gov.org/ehd <br /> 0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> — <br /> ftw PWPN i�f�-2, 0 1 attl <br /> Facility Address: Service Request#: <br /> POM60 Tr <br /> �N 6 06t 06,e7 <br /> Onsite Service Technician's Name: ICC Service Technician Installer Exp.Date: Manufacturer Tr ' ' <br /> LW4 $, F:111 <br /> V V <br /> SERVICE SERVICE <br /> Leak detector 0 mechanical Model: Spill bucket 1:1 minimum 5 gallon <br /> ftLn M5 <br /> El )(electronic Serial #: 2ZOOC2 El 0 1 hour hydrostatic 1:1 Incon TS-STS <br /> 0 line test programmed 0 Caldwell System El Other <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> 0 mechanical Model: — <br /> El El 0 electronic Serial #: 0 1 hour hydrostatic El Incon TS-STS <br /> 0 line test programmed 0 Caldwell System 0 Other <br /> Leak detector <br /> 0 mechanical Model: Spill bucket 0 minimum 5 gallon <br /> — <br /> El El electronic Serial#: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 line test programmed 0 Caldwell System 0 Other <br /> sensor Primary piping testing at: <br /> 0 0 positive shutdown Model: El Psi <br /> El fail safe Serial#: <br /> 0 NA minutes <br /> sensor Secondary containment testing for: <br /> El 0 positive shutdown Model: UDC(s) Piping <br /> 0 fail safe Serial#: Sump(s) LIST(s) <br /> El NA sensor Testing for the above components are next due by: <br /> ❑ 0 positive shutdown Model: <br /> E] fail safe Serial #: Note: Please be aware that 21 containment components are required to be tested upon <br /> E] NA instillation,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% El Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) El Other: see below <br /> -64 h��andlAu VP— PLA'D birio, LOALdfkz&�: <br /> AV d P <br /> k& LeA L ak' 3 ojajjjA-yj e,- 0 r Zt- I Ojo,S I <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> A <br /> EHD 11negetor: I Receive y: Title: <br /> %J <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />