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og4ulN• � <br /> SAN JOAQUIN COUNTY <br /> y' <br /> INVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> . P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigoy.orq/ehd <br /> </PORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service� v-e ZiS t <br /> Request#: <br /> 5avo &49 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp, Date: Manufaicturer Training: <br /> SERVICE SERVICE <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ 111 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: <br /> El line est ro ramm ❑ Caldwell System ❑ Other <br /> td <br /> sensor t <br /> Primary piping testing at: <br /> A?Ojositive shutdown Model:U,e -l9cj-3&7-Z�� ❑ —psi <br /> it safe Serial#:: 0,[�/ <br /> El NA minutes <br /> — <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall 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 /> ❑ NA inslallatian,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 /> his UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> THIS IL TY IS_>WBJECT TO REINSPECTION A Y TIMIg8LEHD1S CURRENT HOURLY RATE. <br /> EHD Inspe r: Re By: Title: <br /> EHD 23 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10 /10 <br />