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o.?'•aU I N••.c <br /> ''a-• '° SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N:I�Y <br /> '.' 600 East Main Street, Stockton, CA 95202-3029 <br /> C',qC I oRN P <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.segov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> F C` Ck)exjyor� 8-16 <br /> 'll <br /> V <br /> Facility Ad ss: Service Request#: <br /> �1 1 A; iCA �5 q)- 1�f-lnqD1La <br /> Onsite Service Tech 'cian' �a 'e: ICC Service Technician/Installer Exp.Date: �Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detectori�,� Spill bucket ❑ minimum 5 gallon <br /> (9 mechanical Model: V ��9� ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial* IDOqI 34S ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ❑ El hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> El El shutdown Model: El psi piping testing at: <br /> El fail safe Serial#: p <br /> ❑ NA minutes <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 /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspectgrn Receive Title: <br /> v�111he LIL' i, <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />