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o.A��l�• � <br /> SAN JOAQUIN COUNTY <br /> Q1 ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> .`,■ 600 East Main Street, Stockton, CA 95202-3029 <br /> P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s*gov.org/ehd <br /> 9«F ORS` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility arae: Inspection Date: <br /> k N1 <br /> Facility A dre s; f ervice' equues�t#: <br /> S�'iD <br /> Onsite Service T Tech Ic en's Name: ICC Service Tech ician/Installs Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector - <br /> ❑ ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: Pri Pry piping testing at: <br /> ❑ fail safe Serial#: psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for.- <br /> El ❑ positive shutdown Model: UDC(s <br /> 11fail safe Serial#: ( ) Piping <br /> ❑ NA Sump(s) UST(s) <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: <br /> ❑ NA Note Please be aware that 2°containment components are required to be tested upon <br /> 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 45( This UST facility is NOT APPROVED to operate <br /> b0`V9.'bQJ&' 11441 RA 14 11 <br /> } <br /> AR <br /> Ca V1 I ti <br /> r <br /> THIS FACILITY IS SUBJECT TO RE SPE TION AT Y TI i AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp r. Re ved By: Title: <br /> 2 <br /> EHD 23-04 <br /> Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT <br />