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`r SAN JOAQUIN COUNTY \, <br /> e' ENVIRONMENTAL HEALTH DEPARTMENT <br /> �6 600 East Main Street, Stockton, CA 95202-3029 <br /> . Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sioov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facili Name: Inspection Date: <br /> ell <br /> Faci tty Address: Servill Req t#: <br /> rte gervice Technician's Na e: ICC Service TechniclanInstaller Exp.Date: Manufacturer Training: <br /> 7-6 _ <br /> SERVICE G SERVICE( <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El 1:1 Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <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 /> El positive shutdown Model: Cl — si <br /> ❑ fall safe Serial#: p <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Surl UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> EDI <br /> ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note Please baa thet wntainmsmaamponentsamrNuired tob testeol upon <br /> ElNA installation,6 months after,al every 36 months thereafter. <br /> Drop tube with mechanical overfill at 95%a LlCold start of monitoring panel <br /> Drop tube with mechanical overfill at 95% ElCorrosion protection <br /> Overfill prevention (see LG letter 150-1) Other: see below <br /> ❑ This UST facility is APPROVED to operate /IV This UST facility is NOT APPROVED to operate <br /> 97 of x ; <br /> T IS FACILITY IS SUBJECT TO REINSPECTI N AT TIME A CURRENT HOURLY RATE. <br /> EHD Ins - Received ay Til <br /> r <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />