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0?'4�1h c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Qr < <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sIqOv rq/ehd <br /> q�l FORI, <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Inspection Date: <br /> Face Ity Name: I`� Z� <br /> r (See vice Request#: <br /> Facility Address: 4 S <br /> Onsite Service I echniclan's Name: ICC Service Technician/Ins ler Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: ❑ ❑—1hour hydrostatic ❑ Incon TS-STS <br /> Ll ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test lDroqrammed <br /> Leak detector Spill bucket f-1 minimum 5 gallon <br /> ❑ mechanical Model: 1 hour hydrostatic <br /> F1 ❑ Incon TS-STS <br /> E] LI <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed . <br /> sensor Primary 1 esting at: (4-7 � <br /> ❑ positive shutdown Model: �G _psi <br /> ❑ ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> 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 /> ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note' Please be aware that 20 containment components are required to be lasted upon <br /> El <br /> installation,6 months after,and every 36 months thereafter. <br /> El NA❑ 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) <br /> ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> IN <br /> 10, <br /> c <br /> - <br /> � o , <br /> THIS FACILITY IS SUBJECT TO REINSP TION AT ANY TI EAT EHD'S CURRENT HOURLY RATE. <br /> e ed By: Title: <br /> EHD Ins p or: V -P� <br /> r <br /> UST SERVICE REQUEST INSPECTION REPORT <br /> EHD 23-04 <br /> Rev 10/06/10 <br />