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op0.0 1,N• C <br /> SAN JOAQUIN COUNTY <br /> ¢r `� ENVIRONMENTAL HEALTH DEPARTMENT <br /> N? 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> + <br /> 0��L� "'**Iq�Ild +# <br /> Facility Address: Service Request#: <br /> V� V*A&111i1y\j ut <br /> Onsite Service Tech ic'an's Name: ICC Service Tec i ian/Installer Exp.Date: Manufacturer Trainin <br /> ,� � t. I� i�-�� �II C�� �i � �� � v ��-l� '��� ��_lc.�` <br /> SERVICE SERVICE <br /> _ Leak detector <br /> mechanical Model: V Spill bucket El minimum 5 gallon <br /> ❑ electronic 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: ❑ El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> - Primary piping testing at:�'.—" <br /> 171 El positive shutdown Model: [ psi t <br /> El fail safe Serial #: T <br /> _minutes~ <br /> ❑ NA <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 /> � e t <br /> ZiMe <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYrTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: civ B : Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />