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o.PQ�I N••.c - <br /> ?' SAN JOAQUIN COUNTY <br /> Q. .A ENVIRONMENTAL HEALTH DEPARTMENT <br /> y 1. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sogov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectjon Date: **�� <br /> ✓ G <br /> Facility Add r ss: Service Request#: <br /> Onsite Service Technician's Name: ICC Ice Te hniclan/nstaller E Date: Manu ac urer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: p�—L� Spill bucket El minimum 5 gallon <br /> ElEl ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> Ja'electronic Serial* ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : ElEl❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El Serial: <br /> El line test programmed <br /> ❑ 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 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 operate <br /> .s <br /> �i <br /> -Pea IoL4 <br /> b 1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTIPN AT A IME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec R ve B Title: <br /> EHD 23-04 ` UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />