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oP4ctN o 0 SAN JOAQUIN COUNTY <br /> >• SFr' o <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.sigov.org/ehd <br /> Q<%PORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name:. Inspection Date: <br /> acuity A dress: Service Request#: <br /> 1-7 I w,t, .r Ggt.a— � �( <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer <br /> Manu acturer Training: _ <br /> Jr- <br /> DO r, 47G ��— 0�— S 6 X—S 13 /1� I �6lir I / " 3 <br /> t Z <br /> SERVICE SERVICE <br /> _Leak detector <br /> ❑ mechanical Model: _Spill bucket 11 minimum 5 gallon <br /> El ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ 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 programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ <br /> 1:1 positive shutdown Model: Primary piping testing at: <br /> ❑ fall safe Serial#: _q psi X„JAIArA.Q MIlieS <br /> ❑ NA L.n minutes p,e .4,ts}- + e <br /> sensor Secondary containment testing fpor: <br /> ❑ positive shutdown Model: UDC(s) t/e. {— Piping <br /> ❑ ❑ fall safe Serial#: SUMP(S) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: <br /> ❑ NA Note: Please be aware Nat 2°containment components are required to be tested upon <br /> 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 '1!1;� This UST facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect Received By: Tito: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />