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OPQUIly C <br /> SAN JOAQUIN COUNTY <br /> X ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> 9�hi 6'R� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Se uest#: <br /> W o K g 7— SOL)44/ c�/V1 n � 1 k Cavtk j; a t 2- <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Ef p.D te: Manufacturer Training: <br /> J � z <br /> SERVICE SERVICE <br /> Leak detector Spill bucket [ Ginimum 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 /> El ❑ mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: <br /> El line test programmed El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> F-1 ❑ fail safe Serial#: Elp psi <br /> El 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 /> FOverfill prevention (see LG letter 150-1) ❑ Other: see below <br /> lvf This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> 5 S <br /> 42-;6 <br /> Ib - <br /> t <br /> Sslb - �v <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO Aj AN <br /> Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD sp tor: Rece' y' Titl <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />