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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> '. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> 9�%KORA <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> CotA G 6 -7b 22 i® <br /> Facility Address: Service Request#: <br /> zs-75 GQ,,,�-�- Gr�� 21,-� <br /> Onsite Service Technician's Name: ICC Service Technician installer Exp.Date: Manufacturer Training: / <br /> sir AI!4.4-7Z-—4 n A Vt„,3/ ,o <br /> SERVICE SERVICE <br /> Leak detector <br /> 11 mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <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: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s)E7 ✓/Q 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 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 /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> a ►-cam-1q--i q// E15T's �4w-f <br /> k • ,'tz h <br /> 1f2btA <br /> THIS FACILITY IS SUBJECT TO REINSP T AT ANY E AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector a By: Title: <br /> /-,- <br /> 7,1A 11 <br /> VV <br /> EHD 23-04 G UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />