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oP4�iy c <br /> >:•.�rr'••.o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> w < <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigov.orq/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection D te: <br /> Si2H mod �' �Q'r //a/// <br /> Facility Address: Service Request#: <br /> 7-1/ 9 e- swooeP/412s <br /> Onsite Service Technician's Name: 1 rvice Technician nstaller Exp.Date: Manufacturer Training:' <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test ro rammed <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: 7! `e D D7 ❑ _psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> 4/II7• sensor Secondary containment testing for: <br /> ❑ positive shutdown Model: VA 790' 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 /> ElElpositive 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) ❑ Other: see below <br /> I This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> vrs- <br /> GUli1.0 D <br /> 07� l�rr� vaZ� <br /> THIS FACILI SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I or: <br /> Received By. Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10106/10 <br />