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ip <br /> 1% " SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigoy.orQ/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facil' Name: I Inspection Date: <br /> Facility Address: Seri Request#: <br /> VA3 <br /> Onsite Service Technician's Name: ICr Service Technician/Installer Exp.Date: Manufacturer Training: <br /> -30 1003 <br /> ER E SE ICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El L1 <br /> mechanical Model: ❑ 1-] 1 hour hydrostatic ❑ Incon TS-STS <br /> L1 electronic Serial#: <br /> 71 line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ El mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 71 electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> El ❑ positive shutdown Model: Primary piping testing at: <br /> El❑ fail safe Serial#: psi <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 /> ❑ fail safe Serial#: Note Please be aware that 2°containment components are required to be tested upon <br /> ElNA 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 /> Ori <br /> _ IZJIF4 _ <br /> P 5s-f <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspecto Received By: / Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />