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% <br /> °p4 <''•.oSAN JOAQUIN COUNTY 'el <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> m. 600 East Main Street, Stockton, CA 95202-3029 <br /> ... P Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> 9�lFOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name:11 Inspection Date: <br /> 1- 6 - 11 <br /> Facility Address: Service Request#: <br /> 191b C-- <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ElElmechanical Model: El EI 1 hour hydrostatic El Incon TS-STS <br /> EI electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> 9/-f1;1161 sensor <br /> ❑ positive shutdown Model: V2 3c,cif- Primary piping testing at: <br /> ❑ fail safe Serial#: 3 Elpsi <br /> 54�,NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) LISTS) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: Note Please be aware that 2°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% ❑ 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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT A <br /> W TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe Received B Title: <br /> EHQ 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />