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otCL c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 606 East Main Street, Stockton, CA 95202-3029 <br /> 4++' • <br /> • Telephone.{209} 468-3420 Fax: (209)468-3433 Web:www.sigov.org/�g�hd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility me: Inspection pa <br /> Facility Addre � �I Dl / Re ue�t®�� <br /> Osite Service Technician's ame: ICC Service Technician/Installer Exp.Bate: Manufacturer Training' <br /> SERVICE SERVICE <br /> Leak detector V1'ho <br /> Spill bucket F1minimum 5 gallon <br /> '7N echanical Model: � _LD j ur hydrostatic ❑ Incon TS'N <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 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 Llsensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#i Note Please be aware that 2°containment components are required to he 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 ❑ Tis UST facility is NOT APPROVED to operate <br /> < <br /> t , <br /> tAll 2; . ? <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Title: <br /> 9 �y <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />