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oPqu t y 1 <br /> a•..�i'•.o� �' SAN JOAQUIN COUNTY 'V- <br /> 2' .y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.s'qov.org/ehd <br /> •(t �P <br /> GrFORa <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Circ l K l I 0310 <br /> Fac lity Address: service0 0 6 1 Reques^ ;Lf <br /> tb410 CA,Yribri S L a7 11 FJ /KXl <br /> Onsite service Technician's Name: ICC service Techniciantinstalle Exp.Date: Manufacturer Training: <br /> F'r�,ol, zaldc�,n� <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 programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El —psi <br /> ❑ fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA ❑ <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fad safe Serial#: Note: Please be aware Mat 2°containment canponents 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 /> ❑ Ove Ill prevention (see LG letter 150-1) Other: see below <br /> Je' This U$Tfacility is APPROVED to operate El This UST facility is NOT APPROVED to operate <br /> Dk i . <br /> N6jk, ID <br /> t <br /> 2 <br /> s <br /> Y101 <br /> 10,Q frablPyli-q <br /> THIS FACILITY IS SU JECT TO REINSPECTION AT ANY TIME AT EHD'S CU RENT OURLY RATE. <br /> EHD Ins r: RecGvSd By_ � / / Tl1e. yG <br /> / liYl Wn/r yr/"•eva...-` <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION <br /> REPORT <br /> Rev 10/06/10 <br />