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SAN JOAQUIN COUNTY <br /> _: Eby_ - •G <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .:. _ .`. 600 East Main Street, Stockton, CA 95202-3029 <br /> c• ; Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> ORT�` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> VAf 4 4--V <br /> z6 �-a VV C) zV — 7 -.--1(-z' <br /> Facility Addr s: Service Re �est#:O� Zo <br /> Onsit Service Tec nician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> h"01 VVAn-1 VP (4 A41 44 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ ❑ 1 hour hydrostatic E] Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El 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% rEE11 Corrosion protection <br /> ElOverfill prevention (see LG letter 150-1) Other: see below <br /> XThis UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> I lJ v v► 1 - <br /> 4 I - <br /> Adz <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD s ctor: Received B <br /> t.4L. RSf r C `4 L <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />