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Op`c C <br /> SAN JOAQUIN COUNTY <br /> ar- a ENVIRONMENTAL HEALTH DEPARTMENT <br /> NE { _ x 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.orq/ehd <br /> cqY/k oR`'�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> ROOM 8l11141 a 2zL I <br /> Facility Address. Service Request#: <br /> 3-7 e,-6 TrU64 o IX t4n a <br /> Onsite Service Technician's Name: ICC Service T chn�ictan/Installer Exp.Date: Manufacturer Training: <br /> - <br /> , vl�— <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> Positive- shutdown Model: — Primary piping testing at: <br /> ❑ fail safe Serial#: El psi <br /> ❑ NA minutes <br /> Secondary containment testing for: <br /> �{ positive Ahutdown Model: UDC(s) Piping <br /> Jam' ❑ 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 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 /> rET] 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 /> -64Chftj204-1A4 6f— T s <br /> k <br /> 01 <br /> I�' i h <br /> D V r`2l `dam <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIM"T EHD'S CURRENT HOURLY RATE. <br /> EHD Ins or: Recei d By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />