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Aqutry <br /> SAN JOAQUIN COUNTY <br /> e ENVIRONMENTAL HEALTH DEPARTMENT <br /> t� � 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> '. Telephone: (209)468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> IFO <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: C Inspection Date: <br /> ^ <br /> t � Jplo (o - <br /> Facility Add ass: Service Re uest#: <br /> 705- CA` fW a e gf3 <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket L] minimum 5 gallon <br /> ❑ <br /> El mechanical Model: El 1 hour hydrostatic Ll Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> E) ❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#:❑ line test programmed 1 <br /> ❑ Caldwell System ❑ Other <br /> CWCtn , sensor Primary piping testing at: <br /> El positive shutdown Model: o+gq�gfl 4420 ❑ —psi <br /> A <br /> fail safe Serial#: minutes <br /> N <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall 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°oonbainment components are required to be tested upon <br /> El 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 /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> I ` olinn 4 &L avuut r <br /> M-ct ;o r � e,o1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect (�1 Received By: Title: L <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />