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o.Pa�I N••c <br /> SAN .IOAQUIN COUNTY <br /> c: + ENVIRONMENTAL HEALTH DEPARTMENT <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 /> gCfFORIJ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> IZ' 23/Ip <br /> Facility Address: Service Request#: <br /> /100 s 1,0arh s►2C) u 6/6 (9 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> -5,oq�GNz�, Z s-Z 4S'O -ur �30(.39 — i//g//( <br /> SERVICE SERVICE <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 /> Leak detector <br /> 11 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial: ElEl1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor _ <br /> positive shutdown Model: 7 t�4 3161"3 1-3 Primary piping testing at: <br /> bail safe Serial #: LJ 7 11�, El psi <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 /> ❑ fail safe Serial #: Note Please be aware that 20 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 /> )11 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> C-PN 2 So w G� 1/ <br /> S 0V <br /> S Gtv <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receiv By: Title / <br /> lec <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />