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oP0.u'N O <br /> �•'� '•O SAN JOAQUIN COUNTY is <br /> 2 +� 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 /> Faci ity Nam Inspection Date: <br /> Facility Address: Service Request#: <br /> an <br /> Onsite Service Technician's Name ICC Service Tech nician/InstaIfer Exp.Date: T4-W—:1acturer Training: <br /> t -7 2 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> 11 electronic Serial#: ❑ Caldwell System El Other <br /> El line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model:❑ El psi <br /> El safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: r UDC(s) 9 I <br /> 1 ng <br /> El fail safe Serial#: Sump(s) . UST(s) <br /> El 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 /> 013 S t. <br /> SM10 fs , <br /> C - 719. o� <br /> i `B IN. <br /> THIS FACILITY ISS CT TO REIN PECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector Received By: <br /> � \ Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />