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gyp•, ....,. C <br /> SAN JOAQUIN COUNTY <br /> a• ,rENVIRONMENTAL HEALTH DEPARTMENT <br /> e: '•2 <br /> N. 1 600 East Main Street, Stockton, CA 95202-3029 <br /> `q P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> �IKpR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> hd 1 N►a� � s2 c' z I <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> eA_>I F-4,�6 -02 X73 UT vK- 1c ( Llfrrl-1L IJ <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket 11 minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> F-1 ❑ electronic Serial:: El El hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System 1:1 Other <br /> sensor <br /> ❑ 1-1positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> El NA minutes <br /> h,CSe� r,)�,/,.t,,,�ensor _t `1 41 Secondary containment testing for <br /> N positive shutdown Model: - 75 —OCA UDC(s) Piping <br /> fl fail safe Serial #: CIL £s'+-c 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 2°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 /> I This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> • ? I1 <br /> 51ZDO 615 19 - Sh&tjC1 L AI-Vt 1/6 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector. / Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />