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o.AqutH °� 1. SAN JOAQUIN COUNTY <br /> zEf •.o <br /> ..,—• i ENVIRONMENTAL HEALTH DEPARTMENT <br /> a: a <br /> N; 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> �q[tFORNvP <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 1 '2- - / 2, <br /> Facility Address: Service Request#: <br /> r9l6 e r�ian's Nam : <br /> Onsite Service TechnicICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> l <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: _Spill bucket ❑ minimum 5 gallon <br /> El El El❑ electronic Serial#: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <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: El _ 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 /> ❑ fad safe Serial#. Note: Please be aware that 2°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 ,A� This UST facility is NOT APPROVED to operate <br /> IF <br /> �e4^fin � .•t0 vl t^r— 1' <br /> THM <br /> FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I pe ReceivedBy: ,� Title: // <br /> W/f/ N,1&7 P <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 111/06/1 <br />