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oPqulN `i <br /> SAN JOAQUIN COUNTY `✓ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N' 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicov.org/ehd <br /> �/PORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fac" Name: Inspection Date: <br /> 0 -0 <br /> Facility Address: Servi a Request#: <br /> s C a Ian r7 <br /> Onsite service Te hnician's N me: ICC Service a hnician/Installer Exp.Date: Manufacturer Training: lrav0 —N 3 <br /> SERVICE SERVICE <br /> _Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> I-] electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ElOther <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: ❑ 111 hour hydrostatic ❑ [noon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El ❑ positive shutdown Model: ❑ _psi <br /> ❑fall safe Serial#: <br /> ❑ NA minutes <br /> — <br /> sensor Secondaryco(Itainment testin for l <br /> ❑ ❑ positive shutdown Model: / �/ UDC(s) r Piping <br /> ❑ fall safe Serial#: 01 91 f �, Sump(s) UST(s) <br /> ❑ NA ` I <br /> sensor Testing for he above components are next due by: <br /> El positive shutdown Model: ,/,mo w/ %Ay!� <br /> ❑fall safe Serial#: Note: Please be aware that r oanlai a components ere 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 /> 3 I' ' 6 <br /> a�� 6 hr <br /> i �° a �w <br /> v � ltl� ao � Ihr <br /> THIS CILITY IS SUBJECT TO REINSPECTION AA TIME AT EHD'S CURRENT HOURLY IkATE. <br /> EMD Inspector: Received By: Title: <br /> A56 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />