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oRau.l"t••e <br /> ? ' a 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 /> UNaD�E�FRORGS`RUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION <br /> REPORT <br /> F cility me: Inspe tion Date: <br /> li A ress I I I INService Request#: <br /> MonLA6 6526 1` CA �ti <br /> 9'(z <br /> nsite rvice c nici n's Name: ICC Service Tech ician/ staller Exp.Date: Manufacturer Training: <br /> Loo, 7 <br /> �'7 -1 . 1/1 - is ou <br /> I-A I 4L1041 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> E] ❑ electronic Serial:: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> 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 /> ❑ 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 /> 1 <br /> THIS FAjCILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: RerAlved By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />