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O'oul�! O <br /> ? ' o 0 <br /> SAN JOAQUIN COUNTY <br /> Q ya ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sogov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> `-C X50 � P - �' 0 7.-�-1I <br /> Facility Address: Service Request#: <br /> I WI W )( X30? <br /> Onsite Service Technician's Name: ICC Service Te hnician/Installer Exp.Date: manufacturer Tramin : <br /> I V12 <br /> IAYVAW ' S <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: El ElElSpill bucket ❑ minimum 5 gallon <br /> El El hour hydrostatic Incon TS-STS <br /> ❑ electronic Serial: <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> I sj�ft sensor <br /> El positiveh sensor <br /> tdown Model: -71 q Sk " Primary piping testing at: <br /> ❑ fail safe Serial#: �14,0�� Elpsi <br /> ❑ NA ivlir; S� minutes <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 20 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 /> his UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> �2 1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received Title: <br /> A <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />