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oo,Qu l!Y. c <br /> SAN JOAQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> .. `, 600 East Main Street, Stockton, CA 95202-3029 <br /> Coq,•-.—.- <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> -„''�P <br /> �rFORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> I I g C Vim) LO i4 ;s e AJc 1 F <br /> Onsite Servide Technician's e: ICC Servi Techmcianllnstaller Exp.Date: Manufacturer Training: f <br /> Lc.v eAk'`NaV11 �h -4� -L)T ( �/Z�1�4�1� lO �' <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ Cl ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial M ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: s <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: p Caldwell System ❑ 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 M 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 M 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 /> tra« PC be>,rcl r Cts'' <br /> 9 <br /> ' Ct4q ro Pre) <br /> p Y.�l d ;->�- &,ns�� Ll"Ai <br /> oW A 11 PgsxJ <br /> LEHD <br /> THIS F CILITY IS SU JECT T REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> I ecto r ; Received By: Title: <br /> EHD 3-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 1r <br />