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Aqu I,N <br /> SAN JOAQUIN COUNTY <br /> Q -+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> ylru 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: 209 468-3433 Web:www.s gov.oir /ehd <br /> A ( ) 1 9 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: In ction Date: <br /> Facility Address: ''•• Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician Installer Exp.Date: Manufacturer raining:— , C3_�Lil <br /> - P 1 r��-IL L, <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ fine test programmed <br /> Leak detector <br /> El mechanical Model: ElElSpill bucket El minimum 5 gallon <br /> El El 1 hour hydrostatic Incon TS-STS <br /> ❑ electronic Serial: <br /> El test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondar Containment testing for: <br /> El positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testinq for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note: PI ase 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% ❑ LOtherssee <br /> ion protection <br /> ❑ Overfill prevention (see LG letter 150-1) below <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate i,itAu 1 <br /> I <br /> At S1 Sr,4111,k. UD <br /> .,h N",oiswN 0 dut <br /> li1t` <br /> >i <br /> T1111111S FACILITY IS SUBJECT TO REINSPECTIOtYAT ANY TIME AT EHD'S bURRENT H URLY RATE. <br /> EHD I <br /> nsp Recei d B Title: <br /> AIr <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 ' <br />