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op4U I,y c <br /> SAN JOAQUIN COUNTY <br /> �Fr-NVIRONMENTAL HEALTH DEPARTMENT <br /> N _ 600 East Main Street, Stockton, CA 95202-3029 <br /> . •.P Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> A�/FORa` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> -�. � IS�� -8-11 <br /> Facil.t Address: Service Request#: <br /> Ons it Service Technician's Name: ICC Service Technic. /Installer Exp.Date: Man facturer Training: $�ru� <br /> oqa... u,,,A0 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: ElElSpill bucket El minimum 5 gallon <br /> ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial: <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) `�'1 `�f Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> El positive shutdown Model: tu Aut 6 �flL-1,, 6k ON <br /> I . <br /> ❑ fail safe Serial#: / � <br /> Note: Please be aware that 2°containment components are req i6 red 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) >a Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Are 1-1* <br /> IA- <br /> C)N KV <br /> IS � . <br /> v, }P,jnfi; •.w �.. � � , `�� � � SSS � 9�'� �[,'it� d"Yf . <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receiv d Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />