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AgU[/y <br /> c0G SAN JOAQUIN COUNTY <br /> e. a ENVIRONMENTAL HEALTH DEPARTMENT <br /> I. <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 /> �fFORt•� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> - � L_ 7Z 1-3// / <br /> Facility Address: Service Request#: <br /> s � bn �a � <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> VIQ- <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: El 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ <br /> [I electronic Serial: El El hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> ❑ El positive shutdown Model: ❑ Primary piping testing at: <br /> ❑ fail safe Serial #: 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 /> El 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 JECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec Received By: Title ,f <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />