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oaa Ulf, c <br /> SAN JOAQUIN COUNTY <br /> IR <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www Sigoy orQ/ehd <br /> d�IFORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: <br /> �, �y/,� �• Inspection Date: <br /> Facility Address: <br /> ( (�/� Service Request#: <br /> awe L ar.9- e 1c.4-0 — �(LOce) 7 <br /> Onsite Service Technician's Name: IC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> If <br /> k liw x (Z-3i-lz <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 <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 rr�tr <br /> ❑ ❑ positive shutdown Model: Prima piping testing at: 9 <br /> ❑ fail safe Serial#: �Psi <br /> ❑ NA �minutes G� <br /> sensor <br /> ❑ positive shutdown Model: Secondary containment testing for: <br /> ❑ <br /> ❑ fall safe Serial#: UDC(s) Piping <br /> ❑ NA Sumps) UST(s) <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: <br /> ❑ NA Note: Please be aware that 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 /> /2P This LIST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> '�M�sc Iw sY- sill L oL <br /> �► <br /> tea,le- -v-vAc <br /> / s s�c.r y <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins p 0 Receiv y: Title: <br /> v ec <br /> EHD 23-04 <br /> Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT <br />