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�oARu"tN'�o <br /> _ •� SAN JOAQUIN COUNTY <br /> z 'y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> a. a Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> ®OR�tia"® p� ®p TANK <br /> ® p� /+ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> e, ri <br /> Facility Address: Service Request#: <br /> I t <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Primary esting at: ) Ct(l <br /> El positive shutdown Model: psi <br /> ❑ fail safe Serial#: <br /> ❑ NA minutes l <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 2e containment components are required to be tested upon <br /> ❑ NA I 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 /> I G W r I <br /> 4, f\" 4,P, A�t 'Plus 4"Nk- <br /> 0, <br /> ,< <br /> MgA <br /> i <br /> �R t <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME T EHD'S CURRE R . <br /> EHD In Receiv B . Title: <br /> i <br /> EHD 23-04STS VICE R QUE INSP TIO REPORT <br /> Rev 10/06/10 <br />