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oPqu�N••.c <br /> SAN JOAQUIN COUNTY <br /> Q. + ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s*gov.org/ehd <br /> 0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Q1 Leak detector <br /> echanical Model Pc� ��.c �-- Spill bucket 11 minimum 5 gallon <br /> &Jyelectronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ElEl1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor %"l P Primary piping testing at: <br /> .�J positive shutdown Model: �1 %7-3 ❑ psi <br /> ❑ fail safe Serial #: 7 CT Jam— minutes <br /> ❑ NA 7-L-ti <63 <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 /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 20 containment 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 /> /13—',This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT TIME T EHD'S CURRENT HOURLY RATE. <br /> ZEHD In Received $ Title <br /> EHD 23- UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />