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oP,�urp�• c <br /> SAN JOAQUIN COUNTY <br /> �F~ G ENVIRONMENTAL HEALTH DEPARTMENT <br /> 500 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 458-3433 Web:www.sogov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: [Inspection Date: <br /> Fac lity�dress: � � vice Request : <br /> w'� A <br /> Onsite Seryice Technician's Name: ICC Service Tech nici nllnstaIler E p. Date: Manufactur r Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> 11 mechanical Model: Spill bucket L) minimum 5 gallas <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test erogrammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> E] El❑ electronic Serial#: Ll1 hour hydrostatic ElIncon TS-STS <br /> L1 line test ro ammed El Caldwell System El Other <br /> positive shutdown Model: � [ 3 <br /> Primary piping testing at: <br /> pi <br /> El fail safe Serial #: 111) Elmsnutes <br /> ❑ NA 01f)Qdr <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 /> El <br /> y:❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 21 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 /> 11 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 /> C20 ate i zw 1_4a I nA & GNt A odg.r <br /> CHIS FACIL Y IS SUBJECT TO'REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD lnsp o . Received B Title; <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/08/10 <br />