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o.P4utN•'Or SAN JOAQUIN COUNTY ..I <br /> e• a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> d P'. Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 5�/PORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: -21 <br /> Facility Address: >1 Service Request#: <br /> *3 5 lam at4 AWL ru S4060-19 <br /> Onsite Service Technician's Name: ICC Service Techniciadlinstaller Exp.Date: Manufacturer Training: <br /> tbet, 02-01-20V21 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: _Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> LJ Caldwell System 111 Other <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 /> ❑ fall safe Serial#: <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: 6011iliI Ifisi <br /> ElElpositive shutdown Model: UDC(s) 7�Piping <br /> El fail safe Serial#: Sump($) v-a�t� 1-� UST(s) <br /> EJNA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fad safe Serial#: Note: Please be aware that 2 containment components am 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 /> N This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Q K <br /> S M s f5urld lAd&1ill,1 Hne <br /> I <br /> THIS FACIL TY IS SUBJECT TO R INSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD ector: Rece d By Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />