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Pq.0 1!y ' <br /> �o.��;.c� SAN JOAQUIN COUNTY <br /> �4 G ENVIRONMENTAL HEALTH DEPARTMENT <br /> N._ I < <br /> 6,0CF=ast Main Street, S` ckton, CA 95202-3029 <br /> Telephone:(21,)9 468-3420 Fax:(200)468-3433 fib:www.sigov.org/ehd <br /> aGhi 5 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fagity Name: / Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> '' �U"' <br /> SERVICE SERVICE <br /> Leak detector <br /> Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System El Other <br /> ❑ line test programmed <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% ElCorrosion protection <br /> ElOverfill prevention (see LG letter 150-1) FX Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> wt i - 1 'U1 <br /> L �', �✓ k <br /> I lv til <br /> 1 S 0�44<- AV 1 U L-P L <br /> 1 <br /> THIS FACILITY IS SUBJECT TO REINSPEC I NY TirIllilEIAT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Recei Title: <br /> V <br /> EHD 23-04 V UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 `� <br />