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4u!N. <br /> Iftes, SAN JOAQUIN COUNTY <br /> er ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.siaov.oM/ehd <br /> d�IFORN� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspect' Dat <br /> Facility Address: Servic Request#: <br /> �{'✓P TVA <br /> 0 hits Service Technician's Name: ICC Service Technicianfinstaller Exp.Date: Manufacturer Training: <br /> �t e f0j4 w2ubill1w kbzol (e,7 <br /> 0.10111 <br /> SERVICE SERVICE <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> E] ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed ElCaldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El El positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> El NA —minutes <br /> nsorN'l✓ t Secondary containment testing for: <br /> ❑ positive shutdown Model: a UDC(s) Piping <br /> ❑ fail safe Serial#: D tII — Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereetler. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% Corrosion protection dil rI 4 j- <br /> ❑ Overfill prevention (see LG letter 150-1) �❑l Other: see below <br /> EI This UST facility is APPROVED to operate p(I This UST facility is NOT APPROVED to operate <br /> 1 /` x v- 2= tqu.4L{ <br /> 1S`V - <br /> All L <br /> THIS F CILITY I SUBJECT TO REINSPECTION hT ANY TIME At EHD'S CURRENT HOURLY RATE. <br /> EH IRe ed By: Title: <br /> +. <br /> EHO 23-04 kr,�Y UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />