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oP441lY. o <br /> �:•�,��''•.o� 0 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> a '` 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> �9CI F ORNnP <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Q� Inspection Date: <br /> 6n /� W-13 <br /> Facility Address: Service Request#: <br /> AA <br /> W g <br /> Onsite Service Technicia 's Na . ]ccS T c' nn/Installer Exp.Date: Manllf 'ning: <br /> Tvv !+ Al5 <br /> SERVICE SERVICE <br /> _Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> 4M S*TV sensor . I Primary piping testing at: <br /> f. poiitiv shutdown Model: 2 ❑ _psi <br /> fd'fail safe Serial#I � _ minutes <br /> ❑ NA <br /> sensor: Secondary containment testing for: <br /> I y ❑ positive shutdown ModelS 9 UDC(s) Piping <br /> J" <br /> El fail safe Serial#—a-- -7 Sump(s) UST(s) <br /> ❑ WA <br /> UQJ An sensor: ❑ Testing for the above components are next due by: <br /> ositive shutdown Model: <br /> ❑ fail safe Serial#: Note: Please be aware that 20 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% ❑ 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 /> p <br /> c _ � oe <br /> S <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD In t Received By: Title,` <br /> EHD 23-04 UST SERVICE+REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />