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oPQutN c • <br /> ?•''�•'t�''•� SAN.IOAQUIN COUNTY <br /> Q - ENVIRONMENTAL HEALTH DEPARTMENT <br /> W.VI:_ <br /> { 600 East Main Street Stockton CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> q�%FORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> 322 fE . I C 9V c � <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> uorKKrl,4, Awya"� !�� "Am <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El : ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial: <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> El positive shutdown Model: El psi piping testing at: <br /> ❑ fail safe Serial#: p <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 FACILITY IS SSUUBBJJECT TO REINSPE ION A NY TIME EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector. /✓ `+^J Rece' dBy� Title: <br /> EHD 23-04 \ UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />