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UI <br /> SAN JOAQUIN COUNTY .,,/ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> �. . <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> d4(I F O'iRN�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectio Date: <br /> �aNrw— ce 3� tv- <br /> Facility Address: Service Request#: <br /> 1 �l, SR <br /> Onsite service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> 7 1 / �� I I t <br /> r SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ 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 /> ❑ ❑ positive shutdown Model: ❑ _psi <br /> ❑ fall safe Serial#: _minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ElElpositive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA F-1sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note: Please be aware that 2°containment components are required to be tested upon <br /> El 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 /> --It This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> eJ� <br /> A <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector Received Title: <br /> 61 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />