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Pq 1N <br /> SAN JOAQUIN COUNTY 41 <br /> 2r ~ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> P Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> 9CIFORN` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: In action Date: <br /> Fac'rty Address: Service Request#: <br /> CI o �+ 4u, <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: anu ac urer Training: <br /> Bron LAKA ely\ t- 222 11 01LI 2 <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 /> nsor ��qq Primary piping testing at: <br /> ❑ positive shutdown Mode'�A–Mq,2KIJ �7t ❑ _psi <br /> ❑ fail safe Serial*�Gi 7�(r�2 minutes <br /> ❑ NA — <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 /> 1:1 NA inslatatioq 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 /> sem , <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In or: I Receiv By: ITi e: <br /> Q <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />