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Nquty <br /> NOW, SAN JOAQUIN COUNTY <br /> 1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> c ..t <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwwsigov.orQ/ehd <br /> q<f F ORt�` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> a WPM 33 16- - ZCl I <br /> Facility d s: Se*e Request�-3 <br /> L <br /> Onsi e Sdifilce Techn c an's Name: ICC service Technician/Installer Exp.Date: Manufacturer Training: p, <br /> SERVICE SERVICE �1 /� <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El El mechanical Model:❑ electronic Serial El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El - si <br /> ❑ fall safe Serial#: p <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 b aware that r mnlainment 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 /> t U4XST-9fid)n 6f U ST <br /> & Ld <br /> r <br /> t, <br /> i m <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHDI e or: Receive By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />