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oq:Qul^!• e <br /> ?•' '•off SAN 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.smgov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> C,v� A rk-i Am� 1_ 0 41 <br /> Facl it Ad s: Service Request#: <br /> Dnsite Service Technician'sI <br /> ame: ICC Service Tech nicianHnstaller Exp.Date: Manufacturer Training: <br /> {cv '� ?—it'11 '7"S'�� <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model Spill bucket � minimum 5 gallon <br /> ❑ ❑ mechanic Serial-. jet hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed El Caldwell System ❑ Other <br /> ,gr 6� . <br /> Leak detector <br /> 1-1 mechanical Model ElEl11Spill bucket 11 minimum 5 gallon <br /> El 1-1 hour hydrostatic Incon TS-STS <br /> 1-1 electronic Serial: <br /> 171 line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> 11 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 /> ❑ fa i I sate Serial : Note: Please be aware that 21 containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> Drop tube with mechanical overfill at 95% LEE] <br /> Cold start of monitoring panel <br /> Drop tube with mechanical overfill at 95% Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) Other: see below <br /> MIThis UST facility is APPROVED to operate 0 This UST facility is NOT APPROVED to operate <br /> biii - <br /> THI§ FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector Recei d By:_D Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10106/10 <br />