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OPq•UI/7. C <br /> �'E '9 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �. 600 East Main Street, Stockton, CA 95202-3029 <br /> eqC�o.R��P <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.s4gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> &a ,-) 1,TZ D - 31 z <br /> Facility A d ss: Servic equest#: <br /> g,G -Q-q 4A` ,-.,r)0 <br /> Onsite Service Technician's Name: ICC Servide Tenn ician/instar Exp.Date: Manufacturer Training: <br /> 9AL CAra4ri, <br /> SERVICE SERVICE <br /> CI I Leak detector <br /> ❑ echanical Model: FALWSpill bucket ❑ minimum 5 gallon <br /> electronic Serial#: " ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed �-�— ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ElEl1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <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 21 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) 1 rO Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> r <br /> y C <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD or: Received By Title: <br /> EHD 23-04 / <br /> UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 t <br />