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OAU I N•.0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N 600 East Main Street, Stockton, CA 95202-3029 <br /> oq�i QR��P <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 /> l vl zv (�J �ti� a vl }-e c e-, S�2 d D , ZG11q- <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Ma ufacturer.Training: <br /> 5 l <br /> ZATQ U ZZ-c rT- G z ► �ro - 3 i <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: El El hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System 1:1 Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other / <br /> sensor Primary piping testing at: 4)1 Ojvd <br /> ❑ ❑ positive shutdown Model: (r!2 psi <br /> ❑ fail safe Serial#: :�j 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 21 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 /> [E] Overfill prevention (see LG letter 150-1) El Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> C - <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rec y-� Title: <br /> (2 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />