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?''��`'••P SAN JOAQUIN COUNTY <br /> Q.- ENVIRONMENTAL HEALTH DEPARTMENT <br /> N � { 600 East Main Street, Stockton, CA 95202-3029 <br /> _ u Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sogov.org/ehd <br /> A�f1=0R�` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> FapHqy Name: Inspection Date: <br /> Facility Address: �4 . Aq Service Request#: <br /> t�ITL <br /> On itis Service Technician's Name: ICC Service Te hnician/Installer Exp.Date: Manufacturer TT ning: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> El — ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial f' ❑ Caldwell System ❑ Other <br /> ❑ line test programmedc�1 <br /> sensor <br /> ❑ positive shutdownyea Primary piping testing at: <br /> ElEls <br /> ❑ fail safe psi <br /> El NA � Y� minutes <br /> d <br /> sensor X�ti Secondary containment test'n for: <br /> ❑ ❑ positive shutdown Mc pts UDC(S) , z°t( Piping <br /> ❑ fail safe Sena. Sump(s) UST(s) <br /> ❑ NA Y crt Si�►�. fit . <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: 611, d T-; -Tq aj0,, j l j'�=��{y <br /> ❑ fail safe Serial#: 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. ;'I l <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> F❑ Drop tube with mechanical overfill at 95% El Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) El Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> uW ,1- iorbWii N ot <br /> a G tvi t ` ► p h.Uiv ivy _l� � �(! <br /> CwNTHIS FACILITY IS SUBJECT <br /> TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect � Receive B : Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />