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ot•4`'''IN.c <br /> SAN JOAQUIN COUNTY <br /> Q' A 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 /> �dC/FO'iRN`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> RL 03 . [il-aoll <br /> Facility Address: Service Request#: <br /> L5 _ 0061 -7-IS' <br /> Onsite Service Technician's Name: ICC Se 'ce lechructantinttallerExp.Date: Manufacturer Training: <br /> Tara g a 20Ua- 6 LP i � <br /> SERVICE '* 3r SERVICE If" <br /> _Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> _Leak detector ill bucket ❑ minimum 5 <br /> El ❑ mechanical Model: Spill gallon <br /> ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> (sensor (fie Ot Primary piping testing at: <br /> Eltive odel: <br /> ❑ posishutdown fit// <br /> ❑ fall safe Serial# 9-agaZ3 I ❑ —psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> El ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: <br /> ❑ NA Sump(s) UST(s) <br /> sensor Testing for the above components are next due by: <br /> El El <br /> positive shutdown Model: <br /> ❑ fail safe Serial#: <br /> ❑ NA Note: Please be aware that 20 containment components are required to be tested upon <br /> 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 ❑ This UST facility is NOT APPROVED to operate <br /> -144( +77.t>- <br /> 2 <br /> d Out I <br /> hO, it <br /> v�nu St1� s <br /> Ind. <br /> THIS FACILITY IS SUBJECT TO REINSPECf ION AT ANY TIME AT EHWS CURRENT HOURLY RATE. <br /> EHD InspTILA— Received By: Title: <br /> EHD 23-04 V <br /> Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT <br />