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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.ora/ehd <br /> UNDERGROUND STORAGE <br /> TORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION <br /> REPORT <br /> Facility Name: Inspection Date: <br /> awl Sh' & i45L <br /> Facility A dre s: V Service Request#: <br /> UoA kea LA LDzL <�K-100b�7 <br /> Onsite Service Technician's Name: Service T nician/Installer Exp.Date: mipnil5a raining: <br /> a IZ12LIJ <br /> SERVICE SERVICE <br /> eak detector <br /> mechanical Model• Spill bucket ❑ minimum 5 gallon <br /> El El Relectronic Serial#: � 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> ❑ NA 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 21 containment components are required to be tested upon <br /> ❑ NA Iinstallation,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 /> is UST facility is APPROVED to operate ❑ This UST facili is NOT APPROVED to operate <br /> 6 <br /> Lm <br /> f . <br /> THIS AGILITY IS SUBJEC TO REINSPECTION AT ANY TIME T EHD'S CURRENT HOURLY RATE. <br /> EHctor: R;eg' d By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />