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Aq.U1y <br /> �o.• .. ..ca SAN JOAQUIN COUNTY <br /> CNVIRONMENTAL HEALTH DEPARTMENT <br /> W.*- ` 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> A�1 FCOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> TL 611 I <br /> Facility Address: Service Request#: <br /> S <br /> 2-3 7 <br /> Ons'te Servici Technician' Name: ICC i Tc hnic� I11sta}I(e�Exp.Date: Mary ctarr( T <br /> r" <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 <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primaps piping testing at: <br /> El El <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model UDC(s) 7 it q11 <br /> Piping <br /> ❑ fail safe Serial#: `Wl r-TP Sump(s) '7 if 41 UST(s) <br /> ❑ NA <br /> sensor 6N Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: t 12112- <br /> 0 <br /> 2- j❑ 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) E Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> c -it ((� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received%k,4 <br /> Title: <br /> e <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />