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UV if c <br /> ?• '•o� SAN JOAQUIN COUNTY <br /> Q -+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> AMR600 East Main Street, Stockton, CA 95202-3029 <br /> .P Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.orq/ehd <br /> Q�hilo, <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> off, o � 28 c 1 <br /> Facility Address: g Service R quest— <br /> 54�/ Wo 60,(r* Mtv!� g-�71 0 062-6 G 2- <br /> Onsite Service Technician's Name: ICC Service Technician/In taller Exp.Date: Manufacturer Training: <br /> 5a5 <br /> 661 911111 K 31�c3 <br /> ,% <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System 11 Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket 1:1 minimum 5 gallon <br /> El ❑ electronic Serial:: El EI1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <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% rEl <br /> Corrosion protection <br /> El 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 /> �P/ 4W <br /> _ � l <br /> ` S W� // _ ). <br /> fA Al <br /> THIS FACILITY IS SUBJECT TO REINSPECTI N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp r: Received Title: , f� <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />