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OPQUr(y• C <br /> SAN JOAQUIN COUNTY ' <br /> _ ENVIRONMENTAL HEALTH DEPARTMENT <br /> K 600 East Main Street, Stockton, CA 95202-3029 <br /> a P. Telephone:(209)468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectio Date: <br /> S'RH mod bas a ► I l9 <br /> Facility Address: Service Request#: <br /> 74'q E. o G��rJ Q � 00 45(0 35 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Trainin : <br /> 2l <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#:El line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> El El fail <br /> fall safe Serial#: ❑ <br /> El 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 2°containment components are required to be tested upon <br /> El 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) X Other: see below <br /> ❑ This UST facility is APPROVED to operate 9 This UST facility is NOT APPROVED to operate <br /> 13` 0 <br /> F P <br /> A10 C <br /> r <br /> &nnoror n Gt' h <br /> THIS FACT Y IS SUBJECT TO REINSPECTION AT AN IME T EHD'S CURREN URLY RATE. <br /> EHD In ctor: Receiv2w Tit <br /> EHD 23-04 <br /> Rev 16//06/06110 ,r�A/�Tll'f,J(((LlJJ,�._�✓��� -�i1 //� > /� UST SERVICE REQUEST INSPECTION REPORT <br /> (/�6�L <br />