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o�QutN O <br /> �••' '••o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y > `. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ��fFOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> QUID -7 <br /> Facili y Address: Service Request#: <br /> CA ql�A <br /> Onsite r ice Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector t Spill bucket* minimum 5 gallon <br /> El mechanical Model: <br /> ElV1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial: <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El 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 /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall 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 /> CeN <br /> 4L <br /> ,N d� a� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspecto F R c ' d By: Title: <br /> Nt'(,Q <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />