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Pqulry <br /> SAN.IOAQUIN COUNTY <br /> 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 /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name:. � In�pectip ate- <br /> Facility Address: U <br /> L12 SerAice <br /> Requestl #: ,.._ <br /> I tj�m <br /> bV <br /> Ons' ervice Technician' Name: S rvice Technician/Inst Iler Exp,Date: Manufacturer Training: <br /> SERVICE SERVICE <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 /> 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 V..32) _ / Primary piping testing at: <br /> El,positive shutdown Model: I ❑ psi <br /> JK fail safe Serial#: I Sy7 A-5 J minutes <br /> ❑ NA <br /> sensor II � l Secondary containment testing for: <br /> El positive shutdown Mbdel: UDC(s) Piping <br /> fail safe Serial#: Sump(s) UST(s) <br /> NA ❑ <br /> sensor �j _ Testing for the above components are next due by: <br /> ❑ positive shutdown Model: -30 <br /> fail safe Serial#: /`7 "/ ` 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 LIS letter 150-1) [qOther: see below <br /> This UST facie iA PROVED o operate ❑ This UST facility is NOT APPROVED to operate <br /> / I <br /> ,t 4 <br /> 4�r'Pull v <br /> sOft <br /> THIS FAC LITY IS SUBJECT TO REINSPECTION AT ANY TIME AT-EHHDD'SS CURRENT HOURLY RATE. <br /> H hr' Received Title: cxv_cx� <br /> i <br /> I <br /> EHD 2104 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />