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oP4�.tN• c <br /> >.•:��••.o� � SAN JOAQUIN COUNTY <br /> _ 'moi/—" '•ry <br /> c .+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> �9�tFORa <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspgcti n Date, <br /> +I fb F /G I a7l Gl <br /> Facility Address: Service Request#: <br /> 74 e -S1200Cb(.01`F2-�5 I <br /> Onsite Service Technician's Name: ICC S6rvlke`Techhicianllnstaller Exp.Date: Manufacturer Training: <br /> VP - <br /> SERVICE SERVICE <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 /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ <br /> El electronic Serial#: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> El ❑ fail safe Serial#: ❑ minutes <br /> ❑ NA — <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 /> ❑ fall 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 Hereafter. <br /> ❑ Drop tube with mechanical overfill at 95% Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> �❑l Overfill prevention (see LG letter 150-1) Other: see below <br /> ,es< This UST facility is APPROVED to operate 11 This UST facility is NOT APPROVED to operate <br /> `• r <br /> aSed <br /> r <br /> ZrtA <br /> t , <br /> b V -704C 421k4 5t <br /> THIS FACILI BJECT TO REINSPECTIWT A HD'S CURRENT HGAFLY RATE. <br /> EHD In ector: Re cei Title <br /> EHD2L / ® k� O _ UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/08//06/10 T (� �I L� <br />