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oa4�liy c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0) ` 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.S ClOv. q/ehd <br /> dq�iPpRN`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Inspect ate: <br /> Faci ity Name: ym <br /> Service Request#: <br /> Facility Address: II Qj_ 0()G!7Z4C-) <br /> eTICC Service Technician/l staller Exp.Datd: Manufacturer Training: <br /> Onsite rvice echnician's Na e: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: - ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ <br /> El electronic <br /> 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 ro rammed , <br /> sensor Primary piping testing at: - `'i f I ¢t s(— <br /> ❑ positive shutdown Model L psi pli <br /> ❑ ❑ fail safe Serial#: minutes <br /> ❑ NA Secondary containment testing for: <br /> sensor UDC(s) Piping <br /> El El <br /> positive shutdown Model: - --- Sump(s) UST(s) <br /> ❑ fail safe Serial#: <br /> ❑ NA ❑ Testing for the above components are next due by: <br /> sensor <br /> Elpositive shutdown Model: to be tested upon <br /> El fail safe Serial#: Note Please be aware that 21 containment components are required <br /> L1 <br /> installation,6 months after,and every 36 months thereafter. <br /> ❑ NA <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% <br /> ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) <br /> El Other: see below <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> S S 1 <br /> Ito) ` <br /> _ S <br /> 0 <br /> • s <br /> - p <br /> THIS FACILITY IS SUBJECT TO REINS CTI N AT ANY ME A HD'S CURRENT HOURLY RATE. <br /> ec By: <br /> EHD Inspe or <br /> UST SERVICE REQUEST INSPECTION REPORT <br /> EHD 23-04 <br /> Rev 10/06110 <br />