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OPQ'Ut,N C <br /> SAN JOAQUIN COUNTY <br /> �-+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> �. 1 600 East Main Street, Stockton, CA 95202-3029 <br /> ' Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.segov.org/ehd <br /> OqC O�R�;P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> , (S /v <br /> Facility Address: Service Request#-.- <br /> NO3 <br /> :103 t. j4P:z o v. <br /> Onsite Service Technician's[dame: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> ly / x- 0 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket 11 minimum 5 gallon <br /> : <br /> ❑ <br /> F-1 electronic Serial: El El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket L1 minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ El hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> 171 ❑ fail safe Serial#: 5wo psl <br /> �� <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: (5r; <br /> El El positive shutdown Model: UDC(s) 7 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: �`��,� 'rj_ 7--V lr> <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 /> >^w a- n n ^64r- n 5A <br /> ,rd tt 1 1,jat 1W, 16)10. <br /> THIS FACILITY IS SUBJECT TO REINSPECTI N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />