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ON <br /> SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fan: (209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: & insp coon Date: <br /> I <br /> Facility Address: x1 Service Apnueit#: <br /> ` J (4V, D <br /> Onsite Service echnician's Name: ICC ServiceTechniciantiln taller Ex .Date: Manufacturer Training: <br /> FiA <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 /> ❑ positive shutdown <br /> sensor Wt <br /> Model: IIIA� ElVa Primary piping testing at: <br /> fl7D' i3 _ <br /> ❑ fail safe Serial#7 psi <br /> ❑ NA minutes <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 /> ❑ •❑ positive shutdown Model: <br /> ❑ fall safe Serial#: Note: Please be aware that 2 containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and awry months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ElCorrosion 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 /> lZJ \ <br /> e <br /> �:6us�- <br /> THJS FACILITY IS SUBJECT TO REINSPE TION AT ANY T E AT EHD'S CURRENT HOURLY RATE. <br /> EHs r: Re Ived By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />