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PquIN • <br /> �o.�t.coG SAN JOAQUIN COUNTY <br /> Q' is ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> '. Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> L/PORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> -7- 11 ayd, l 10/i 11 <br /> Facility Address: Service Request#: <br /> LG 1 ltl-� 9 9h Sero m S12C)O6 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> PJ1sScA GJGtGI � IG(. 5;1 13 I/MZ 257 <br /> SERVICE SERVICE <br /> Leak detector V L V Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: —D 61 ❑ ❑ 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: El El hour hydrostatic 71 Incon TS-STS <br /> El electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ _psi <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 that2°containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% 1�& 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 /> w Sz <br /> p ONS <br /> Get <br /> Gt {vrPli <br /> Ly <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rece ve By. Title: <br /> El 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />