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R �°p0.utN''•�o <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL 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 /> 4<<F ORa` <br /> UNDERGROUND STORAGE TAM( (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> 4 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: 7C 11 J11 <br /> 5� <br /> +en Fre,.,UL <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model , Spill bucket minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ 1 hour hydrostatic Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El 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 /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si <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 Iinstallation,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 /> ell <br /> !� at <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHDIns Recei d By Title: <br /> A <br /> 64� i <br /> EHD 23-0 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />