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AgUIN <br /> SAN JOAQUIN COUNTY <br /> N y{ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> `o-.. Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> a�1 io <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> F cil Name: Inspectionate: <br /> vhewi M449024� 1, i - i ' <br /> Faility Address: Service Request#: <br /> 1061 - lob <br /> Onsite Service Tecni 'an's Name: IC ervice echnician/Ins le Exp.Date: Manufacturer Training: <br /> X25 z� Z k7,5bD) <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial: El 1 hour hydrostatic El Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon" <br /> ❑ ❑ mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> positive shutdown Model: Primary piping testing at: <br /> fail safe Serial#: El psi <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 /> THIS FACILATY IS SUBJECTTO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH n e or: Received By Title: <br /> a►. <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />