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'O p,q V t N•.C'� <br /> .� SAN JOAQUIN COUNTY <br /> air ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468••-3420 Fax:(209)468-3433 Web:www.siaov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Fact ity Address: Service Request#: I <br /> cl� 144 a t ° , -t <br /> On to Service Technician's Name: ICC Service Technician/nstaller Exp.Date: Manufacturer Training <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> 1771 ❑ electronic Serial:: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ 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 /> 1-W, sensor ,` `1 ❑ Testing for the above components are next due by: <br /> positive shutdown Model: \1"4 6f <br /> Wail 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 /> M j <br /> 4 C <br /> 3 `? <br /> I <br /> 71 <br /> U t1i <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect moved By: TT111e. <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 i <br />