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�oPq,u ty o0 <br /> SAN JOAQUIN COUNTY <br /> ?=NVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> `P.. Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.or /g ehd <br /> pg <br /> A<;F o <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: i <br /> ii pp <br /> 11 <br /> -Va-cilffy Add ess: Service Req 'est#: <br /> Im n aA CAq fg' 61 Vk ifi-elf" C462�1 P ob 2-40 4� <br /> Onsite Service Technician s Name: ICC Service Technicigg n/Installer Exp.Date: I Manufacturer Training: gg <br /> I ' [ <br /> e <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 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: .. ❑ psi <br /> ❑ fail safe Serial#: 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 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% El Corrosion protection <br /> ❑ Overfill prevention (see LIS letter 150-1) ElOther: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> A. <br /> s <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe or: Ret <br /> e ived By: Title: _ <br /> 'ct <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />