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o?'•4UIN• c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q: a <br /> N. I . 600 East Main Street, Stockton, CA 95202-3029 <br /> �.. <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sogov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> 4t��> I <br /> Onsite Service TechniciafP's Name: ICC ervice Technician/Installer Exp.Date: Manufactu er Train•' g: <br /> 2 <br /> Mf- /r,--�- 12-I I-1 ! - 2 �� ` --28-11 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: 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: ElEl1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> 71 positive shutdown Model: Primary piping testing at: 8 9' I <br /> El El si � ' t <br /> �fail safe Serial #: ' , <br /> El NA minutes c4y<(V16 �. <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 LIST facility is APPROVED tooperate' <br /> ,r Il 'Tois UI T facility i$ OT�PPROVED to operate <br /> �Z , <br /> tJ �lat� ' � � ' <br /> I <br /> IVO t <br /> t <br /> 'W"fRA 46 1i rW s sejt%. <br /> ScIij V'm ulw' W%, At 646 d ne <br /> c " -x 64 aw aleid 4N E <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE.' <br /> EHD Inspector: R v By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />