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OPQUI(y. C <br /> SAN JOAQUIN COUNTY 40 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .: `. 600 East Main Street, Stockton, CA 95202-3029 <br /> . .p Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.or /q ehd <br /> A�fFOR�` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facili Name: Inspection Date: <br /> /v <br /> Facility Address: 1 nn Service Reequ_�esst'#: <br /> Onsite Service Technician's N me: C Se ry ce Technician/Installer Exp.Date: nufacturgr Tj•ai�in�.k 11Q 3 <br /> MSL. �C h / <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El positive shutdown Model: (' <br /> ❑ Elcn <br /> fail safe Serial#: , psi �1k,dl� 1 p <br /> ❑ NA minutes <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 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 O-(— 3 <br /> THIS FACILITY IS SUBJECT TO REINSPE 10 AT ANY T ME AT EHD'S CURRENT HOURLY RATE. <br /> EHDI e or: R� Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />