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°t0.utN SAN JOAQUIN COUNTY <br /> r. t ENVIRONMENTAL HEALTH DEPARTMENT <br /> wt.hil600 East Main Street, Stockton, CA 95202-3029 <br /> P.. Telephone:(209)468-3420 Fax: (209)468-3433 Web:wwwsigov.org/ehd <br /> •fGIFORN` <br /> UNDERG OUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Namd Inspect'im Date: <br /> yam,, T mrd ` G 05----2-6 - I i <br /> Facility Addre : Service Request#: <br /> -10`l 5 �d-2� 12WA 00 02,6f S <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> 0-2-(r[z <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 /> ❑ mec anical Model: <br /> El ❑ elect electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> posi ve hutdown Mo el: Z ❑ _psi <br /> ❑ fail safe Serial#-� <br /> El 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 be a,vare that2^oonlainment components are required to hetested 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 ❑ This UST facility is NOT APPROVED to operate <br /> / b t. "If/ <br /> ,VyI <br /> THI FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp o d By: Title:'- <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06110 <br />