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op,CL- c <br /> SAN JOAQUIN COUNTY <br /> er Za ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> • ;P Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> q�1 FOFRa <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Wilk* Na Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician'sName: ICC ervice T chnician/Installer Exp.Date: Manufacturer Training: <br /> rc- 113 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ 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 <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial: El El hour hydrostatic El Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> c. J'o sensor4iI v Litie- <br /> ❑ positive shutdown vlVfddel: � Primary piping testing at: <br /> ❑ fail safe Serial#: I 0O W " Elpsi <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 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 /> E <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receive Bye Title: <br /> ./Z/ hez-41 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />