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Aquiy <br /> SAN JOAQUIN COUNTY • <br /> y; s` ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siaov.org/ehd <br /> 'f�/FORS\ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: t I <br /> 5 J c �e b ► IfJ a(� <br /> Facility Address: Service RequestA <br /> I5 33 E, �rlds � S +�f� s� 3©0 <br /> Onsite Service Technici 's Nape ICC Service Techniciantinstaller Exp.Date: Manufacturer Training: J d.j� 2 <br /> 0'e <br /> $� a l� g a i�°oq �T I zo 13� ly,0411, 7C IOITA <br /> SERVICE SERVICE <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> El ❑ electronic Serial#: L1 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> _Leak detector Spill bucket I-] minimum5 gallon <br /> ❑ mechanical Model: <br /> ❑ <br /> El electronic Serial#: t El 1 hour hydrostatic ❑ Incon TS-STS <br /> El line est ro rammed ❑ Caldwell System El Other <br /> I pees+. sensorI j I11 Primary piping testing at: <br /> rn ❑ positive shutdown Model: Kl r I S —1 C ❑ psi <br /> 7� ❑ fWi- a Se�sd Serial minutes <br /> ❑ NA t <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 /> ❑ fall safe Serial#: Note: Please be aware that r 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 /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> a 2 � . <br /> i 5 r we <br /> THIS FA.CNITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe r: Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />