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o?Q"tN 'Q SAN JOAQUIN COUNTY <br /> a: + ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.segov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> �59CO6-301 35 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> 7 1 z �3 �— 7 — /3 <br /> r <br /> SERVICE SERVICE A:—Q!;4 <br /> Leak detector <br /> EI mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ❑ El hour hydrostatic E] Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> r3 7!1 he- sensor <br /> El positive shutdown Model:VK -33�/?-�-�> Primary piping testing at: <br /> ❑ psi <br /> ❑ fail safe Serial#: <br /> . -RIA 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 /> ❑ 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) -ja Other: see below <br /> L( This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> /vii AGuv\ r <br /> c III, <br /> -7_ _1 , <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY f IME AT D'S CUR ENT HOUR Y,RATE. <br /> EHD Ins r:Al Receiv Title: <br /> l"' {C <br /> EHD 23- �tlVUST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />