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o�gUly <br /> 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 /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician'sblame: ICC Service Techniciatnlinstaller Exp.Date: Manufacturer Training: <br /> /ie, "T`�•_ x" ��?i� t 1 X '��7 1 /?r 'a� o��— 5—ZZ s fJ <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ Q mechanical Model: p ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: ❑ Caldwell System ❑Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑minimum 5 gallon <br /> ❑ El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: <br /> ❑ line test programmed ❑Caldwell System ❑Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ,g, 5J si <br /> ❑fail safe Serial#: p <br /> ❑ NA _minutes <br /> sensor Secondary containment testing for: (5;[ <br /> ❑ ❑ positive shutdown Model: UDC(s) 757 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: G� <br /> ❑fail safe Serial#: NoteNote. Please re that r containment components are required to ue tested upon <br /> ❑ NA installation,6 months atter,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 /> �- -c- L4 Aota-"- ,s S s 6 <br /> rrt + arn+11rte.. f' s .� An <br /> lr <br /> �* N a. ��✓`�. <br /> THIS FACILITY 1S SUBJECT TO REINSPECTi N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD tnspe Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Riv 10/06/10 <br />