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Ot'4UIN' C <br /> ? ' r''•P SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ¢: a <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> c. P.. Telephone:(209)468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> 9�rFORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fac��it N""ame, Inspectio Date: <br /> Facility Address: Service Request Ill <br /> Il fl Ill,/, EeN- AORA (90 &1�;o I <br /> On It Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> ►'�1 U T n VM I 1 <br /> SE VICE SERVICE <br /> Leak detectorI Spill bucket El minimum 5 gallon <br /> 1°i <br /> mechanical odel: a� — 2(JCY EJ ❑1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El 11 mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: 11 Caldwell System El Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> El ❑ positive shutdown Model: ❑ _psi <br /> ❑ fall safe Serial#: <br /> ❑ NA minutes <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 /> ❑ fall 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 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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT El CURRENT HOURLY RATE. <br /> EHD sector: Received T le: <br /> 6ltGG/GG�^ <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />