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pe'4�I iY, <br /> ? ' �'••P SAN JOAQUIN COUNTY <br /> e � .y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ` Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.s'gov.org/ehd <br /> �tFORa` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facil' ame: Inspection Date: <br /> Facility Address: Service Request#: <br /> f sf i DD 6 <br /> Onsite Service Techrhcian's Name: ICC ice T ch ician Uer22M.Date: Manufacturer Training: <br /> I� J VR 1,,,A 4 069?jZ <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: _Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ <br /> El positive shutdown Model: ❑ Primary iping testing at: <br /> ❑ fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above compon ns re next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: Note: Please be aware Net 2°containment components are required to be tested upon <br /> ❑ NA instailation,6 months after,end 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% 91 Corrosion protection�ItL� r l;5 <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 /> (t <br /> S i <br /> l 4- rAutim nIrno;iL-kj I f�A Ar- 11461 <br /> U <br /> �p <br /> t <br /> & <br /> Spee( <br /> THIS FA ILITY IS SUBJECT TO REINSPEC N AT AhlI ATE 'S CURRENT HOURLY RATE. <br /> EHD in eat r: By: Title (/ JtS <br /> EHD 23-04 UST SERVI E REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />