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oP 4u I N•.c <br /> SAN JOAQUIN COUNTY <br /> Q: a ENVIRONMENTAL HEALTH DEPARTMENT <br /> N: < <br /> '. 600 East Main Street, Stockton, CA 95202-3029 <br /> _ Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sogov.org/ehd <br /> 15 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 2-jqr C' <br /> Facility Add ss: Service Request#: <br /> i13�I 0 W(--qi r " w" k Sizo6G19f9 <br /> Onsite Service Technician's Namb: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> 1r� (�' Z U I j I( I/I`� 3� l '3I GO <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ <br /> El electronic Serial: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System 11 Other <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 /> V.�C LALA vv-\ .sensor 'S 5 1 c, <br /> El positive shutdown Model: Primary piping testing at: <br /> El psi <br /> El 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 /> ❑ fa i I safe Serial#: Note: Please be aware that 2°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 /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to 91k%te <br /> Wv V(VC v -6, I �^^ Vow C Ll CA t•►- �,Cv vu,%/ rtlj a S b <br /> 6� I�6 Cpl Y-1 LL-mv, vv�-( <br /> VL wvv�GC/ti tiGL� t.✓ fD p �Yn��4 tccv� /�/W rv►,l, }, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: y Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 A/ <br />