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PQulry <br /> >¢'9t91 o <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ., P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siqov.or <br /> _q/ehd <br /> 9�,FOYR \ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: <br /> �- Inspection Date: <br /> Facility Address: <br /> Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Ex P.Date: Manufacturer I I, InI , �j ,IA <br /> .�,- 7i 5/lofy <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 ro rammed El Caldwell System ❑ Other <br /> _Leak detector <br /> ❑ ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> S4 sensor <br /> ❑ positive shutdown Model:V 37.3 Primary piping testing at: <br /> ❑ fail safe SerialPsi <br /> #: _Lh/ FRn ❑ _ <br /> NA _minutes <br /> sensor Secondary containment testingfor: <br /> 0 fail F-1 ❑ positive shutdown Model: UDC(s <br /> ❑ NA safe Serial#: \fes l— Sump(s) UST(s) <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: <br /> ❑ NA Nola: please be aware that 2°containment components are required to be tested upon <br /> installeton,6 months after,and awry 36 months thereafter. <br /> F-1 _Drop tube with mechanical overfill at 95°/p ❑ 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 /> r <br /> -.r- <br /> r <br /> - ++ ^— r <br /> TYW l q <br /> E 5. <br /> h SM1ti � h <br /> THIS FACILITY IS SUBJECT TO REINSPECTION A NY TIMEEHD'S C RRENT HOURLY RATE. <br /> EHD Inspec Received <br /> Title: <br /> EHD 23-04 <br /> Rev 10/06/10 11.0 1,: 11i: UST E ICE R QUEST INSPEFTIpN REPORT <br /> G(j/I✓J <br /> �St' p55s4-Q. <br />