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ut <br /> SAN JOAQUIN COUNTY <br /> -.1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> N:•.:..'L, tit <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209) 468-3433 Web:www.segov.org/ehd <br /> FORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> n�4-- i•-�) --ui 1 <br /> Facility Address: Service Test#: <br /> T 0022 L-1,-2 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date. Manufacturer Training: <br /> 0--1.0-1,[z V C *Q -30 , 1 Z <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ El hour hydrostatic ElIncon TS-STS <br /> El line test programmed El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> E] ❑ electronic Serial:: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> M sensor <br /> fd positive shutdown Model: ��-�D75 Primary piping testing at: <br /> El21ail safe Serial#: ��� —1 q Sz 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 21 containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> ❑ j Drop tube with mechanical overfill at 95% Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Mr <br /> Overfill prevention (see LG letter 150-1) Other: see below rg'W <br /> L S i <br /> SpL 16VI K. <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility " N-T APPROVED to operate <br /> � �&in c4 (,OLJt unt. <br /> V'IZ 5TIP SI.( <br /> VnG rn <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec r: ived By: Title: <br /> GC <br /> E H D 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />