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op'•a�IN• c <br /> SAN JOAQUIN COUNTY <br /> 'Z <br /> 2 ^~rENVIRONMENTAL HEALTH DEPARTMENT <br /> Q: a <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: (, r <br /> 1 Y <br /> 6 Ll- Am <br /> Facility Address` Vic Re est#: <br /> Onsite Service Tech c'an's a ICC Serv'ce Technician/Installer Exp.Date: Nra6ufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ echanical Model: —�rj Spill bucket El minimum 5 gallon <br /> ;A-'electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line t r rammed El Caldwell System ❑ Other <br /> tl e or Primary piping testing at: <br /> positive shutdown Model: 3�' ❑ psi <br /> El fail safe Serial#: <br /> El NA minutes <br /> SI, nsor h i I\u Secondary containment testing for: <br /> ❑ positive sh tdown Model: q�L_d 4 UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor V)e, ❑ Testing for the above components are next due by: <br /> El 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) ❑ Other: see below <br /> •.Rr This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> N41�Ioz <br /> f. . _h el�- Are/ PC3 b <br /> Qq s l <br /> All <br /> reA <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe o • Received B Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />