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Pq.0 t ty <br /> �o ca SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> NAY 600 East Main Street, Stockton, CA 95202-3029 <br /> ;P Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.segov.org/ehd <br /> q�IFORa` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> FP <br /> Fa 'lity Name: Inspection Date: <br /> F t Fa <br /> S ice Request#: <br /> K�. <br /> Onsite Service Tec ician's Name: ICC Service Technrcianlinstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector , bucket Spill III minimum 5 gallon <br /> ❑ mechanical Model: <br /> El ❑ electronic Serial: ,D 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector '�A I Spill bucket minimum 5 gallon <br /> ❑ ❑ mechanical Model: >�P l hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Q;7 hr t I Primary piping testing at: <br /> ❑ positive shutdown Model: I� VAId, ❑ psi <br /> ❑ fail safe Serial#: a 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% ❑ Corrosion protection <br /> T 1-11 <br /> Overfill prevention (see LG letter 150-1) 16,4 ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> t - <br /> nrl� pie <br /> t s. k I <br /> p ( <br /> r <br /> � n 1 Q <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector r/�A� Rseq�`�- Titles <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />