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oPa�I N••.c <br /> SAN JOAQUIN COUNTY <br /> e' ENVIRONMENTAL HEALTH DEPARTMENT <br /> . 600 East Main Street, Stockton, CA 95202-3029 <br /> _ Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.org/ehd <br /> CgCt F OR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> a I of-2- <br /> Facility Name: Inspection Date: l <br /> 0-3�� 2A <br /> Facility AddressQ* L�D� <br /> Service Re Request <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> 1-1 mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ 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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ 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 /> ❑ 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 /> `re <br /> b(R Y e r r- <br /> ani 3 <br /> L (-, - It IM <br /> I G �?� r l ) �- G 2v D , <br /> j AIA <br /> (I MA lfiakdd 0 I-Malf 4i C4�&- Am 121AA. , iv&v �C- azlw -Rbm <br /> A- 1 1&, olek 4T) '-!6�1144 -(�r I-m4nju <br /> THIS FACILITY IS SUBJECT TO REINSP CTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In r: $Z.eived B Title: <br /> EHD 23-04 UST SERVICE QUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />