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AquiN <br /> SAN JOAQUIN COUNTY <br /> a :err-4 ENVIRONMENTAL HEALTH DEPARTMENT <br /> N < <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> 9�1FOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: // Service Request#: <br /> (U <br /> Onsite Service Technician's N me: ICC Service echnician/Installer Exp.Date: Manufacturer Training: <br /> CLL!, 6 ® l 73/r4t3 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si <br /> ❑ fail safe Serial#: p <br /> ❑ NA minutes <br /> 91 I sensor Secondary containment testing for: <br /> ❑ positive hutdown Model UDC(s) Piping <br /> ❑ fail safe Serial#: Surri 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 /> VDrop tube with mechanical overfill at 95% ElCorrosion protection <br /> 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 /> le- <br /> I <br /> l( <br /> B® � <br /> ® r <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins r: Received y: Title: <br /> "o, 1AA�A <br /> EHD 23-0 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/1 <br />