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. .- <br /> '' � SAN JOAQUIN COUNTY <br /> -ter a ENVIRONMENTAL HEALTH DEPARTMENT - <br /> b 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sioov.orQ/ehd <br /> �tFORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fac_ivlity' Name: / Inspection Date: <br /> / �t <br /> ' 1 Grr )Q <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC n/Installer Exp.Date: Manufacturer Training: <br /> s (2 I i-/3--/3 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ ❑ mechanical Model: El ❑ 1 hour hydrostatic 71 Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed LICaldwell System ❑ Other <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El ❑ 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 /> El ❑ positive shutdown Model: ❑ si <br /> ❑ fall safe Serial#: p <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail 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#: Note: Please beawarethat 2°containmenlcomPonenlsamrequired tobetested upon <br /> El NA installation,s months after,and every%months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% /f' 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 /> 1113 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> cr CJI ST G-r T • FI� '1 r..l r.1 <br /> c, 4�- 4 <br /> 3e�L! 4e S 6 cr,-fur _ <br /> IS FACILITY IS SUBJECT TO REINSPECX NAT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EH nspecto Receiv Title: <br /> E -04 �' UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/0 0 <br />