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p4u! <br /> �°•�i''£o� 0 SAN JOAQUIN COUNTY <br /> 2rENVIRONMENTAL HEALTH DEPARTMENT <br /> ¢: a <br /> ` 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.siqov.org/ehd <br /> •Cq •a — �P <br /> GIFORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 2 7r <br /> Facility Address: Service Request1,10 #: <br /> i �— //n� ,^, rr nn l 066 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> �f1 ZO <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 /> ❑ lini test ram ed <br /> 01 nor Primary piping testing at: <br /> positive shutdown Model: El _psi <br /> F] fail safe Serial#: minutes <br /> ❑ NA <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 /> El ❑ positive shutdown Model: <br /> ❑ fad safe Serial#: Note Please be aware that 2-containment components are required to be tested upon <br /> ❑ NA Installa0on,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 LIS letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Iv <br /> r t . <br /> THIS FACILITY IS S BJECT TO REINSPECTION AT ANY TIVE AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins r: Rece ed By: Title: <br /> �- I Fo-,^t T <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />