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4��4� <br /> SAN�JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> C. 1 - 10- 11 <br /> Facility Address: Service Request#: <br /> 2� - I" L � CA R ("'1538(:7 <br /> &nsit,�service Technician's Name ICC Service Tec nician/Instal er Exp.Date: Manufacturer Training: <br /> I'2-I -IAw,�� ��� <br /> SERVICE SERVICE <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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ee b&,psi <br /> ❑ fail safe Serial#: <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 /> FO --Overfill <br /> Drop tube with mechanical overfill at 95% ElCorrosion protection <br /> 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 /> N "Al4im S `to a I a <br /> SY • <br /> Inn 1 <br /> 4 <br /> I Ove sk( 8-7 427/,jc� SO PSW 64-1. <br /> THIS FACILITY IS SUB ECT TO REINSPECTION AT ANY TIME D'S CURRENT HOUW RATE. <br /> EHD Inspector: Re Tit <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />