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SAN JOAQUIN COUNTY <br /> - y-+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> y X <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orq/ehd <br /> UNaD�E1FRORGSROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST <br /> EQUEST INSPECTION <br /> REPORT <br /> Facility Name: Inspection Date: <br /> ska -17L�Ae, 0r <br /> Facility Address: Service Request#: <br /> C &&4 L� <br /> Onsite Service Technician's Name: ICC Service Technician/In r Exp.Datd: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ lie est programmed <br /> ensor Primary piping testing at: <br /> mopositdsit, <br /> ivshutdown 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 21 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 /> ,,0""This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> S <br /> igtif <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I pe or: Recei By: Titl <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />