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P4D'N • <br /> 0 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> r P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.oro/ehd <br /> gCikoRN� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> FF tliTy Name: Inspection Date: <br /> 7V'C 04 s & L� W D — k -Z�I <br /> Facility Address: ,r ehtAq "�1 —O <br /> ro <br /> Onsite servicechnic' n's Name: IICC(;tiii a Technician/Installer Exp. Date: of tu 'r r'fr in ,I <br /> d1 J C( 6 <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 /> sensor Primary piping testing at: <br /> ,B positive shutdown Model: Vf— �� �� ❑ _psi <br /> fail safe Serial#: minutes <br /> L1 NA <br /> sensor '�,.r�7.�,!! Secondary containment testin for: r1yWn <br /> osi ive <br /> d pshutdown Model: -jj4' *V 206 UDC(s) Piping <br /> H fail safe Serial#: 10 Sump(s) UST(s) <br /> ❑ A ❑ <br /> sensorq Testinafor the above components are next due by: <br /> ❑ positive shutdown Model: R I <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%months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% L1 Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operatepp -�g This UST facility is NOT APPROVED to operate <br /> V Or r7K, r <br /> P-b <br /> 06 Fsn - t P la <br /> r <br /> ro r. S <br /> rt <br /> r, Q,� . <br /> THIS FACIL TY IS SUBJECT t0REINSPEdTION AT A NY TIME AT EHD'S CURRENT Hb&RLY RATE. <br /> EHD Insp ReceinDA v B . <br /> Title <br /> EHD 2M4 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />