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oPquly c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q: a <br /> W: <br /> . 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> O:,RN�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 060W 03-,x'20 <br /> Facility Address: Service Request#: <br /> 00 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: o I *a 12- <br /> Chris 4 5 `1 � � o,S 16z VI2 6-Po )L4- -W b z <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket 11 minimum 5 gallon <br /> E] ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System E] Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> ❑ 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 20 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) 01 Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> �Pr✓� �► gldnmS am03 h f~ fli►�svY3. <br /> i in di sem IV rt r z <br /> ` - a+ vv,- 'We <br /> LjbL <br /> r- )(q00 e6-7,3 a f,1,Xq 07 <br /> to 21K 6 <br /> �* rho <br /> THIS FACILITY-11S SUBJECT TO REINSPECTION AT ANI TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD n c r: Received By: Title: <br /> , s T <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />