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OAgU I N-•.0 <br /> ? � P SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 Web:www.s*gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> A Pm 0;aL-15-- <br /> Facility Address: Service Request#: <br /> 191� 1 ��eLAry 006 P <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> I�=`-► f <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El E] Model: ❑ El hour hydrostatic E] Incon TS-STS <br /> El electronic Serial#: El Caldwell System 1-1 Other <br /> El line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> sensor <br /> El El positive shutdown Model: Prim piping testing at: 5 PSIS <br /> r tes <br /> ❑ fail safe Serial#: minu es <br /> ❑ NA :zb <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) r1:11Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> K f <br /> V &. <br /> i <82 <br /> THIS FACILITY IS SUBJECT TO REIN CTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I tor: Rec ived By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />