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4O1N6SAN 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.sigov.orq/ehd <br /> Ci`t<I F p'{iN�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fac 't Name: inspection Date: <br /> NQS 3a II <br /> Facility Address: Service Request#: <br /> --I4 ri r; wa-q h S►2oo�(.vi;53 <br /> Onsite Service Technician's Name: ICC Service Technics n/Installer Exp.Date: Manufacturer Training: <br /> or�arhar l2�olfF x. �o , V1:2 <br /> SERVICE SERVICE <br /> _Leak detector _Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: fEl <br /> ❑ 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 /> El ❑ 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 /> El fail safe Serial#: _minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Suni 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 /> ElNA 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 /> c <br /> Q/7 <br /> o42a <br /> s ar U C rnnro �' mr7 �! <br /> ate / r <br /> Q <br /> ,— s h/ D of-sLi�r� <br /> THIS FACILITY IS SUBJEC TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received T <br /> EH 23-04G( hFes# ICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />