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�,qu!N <br /> ?°'= -+F't FP' SAN JOAQUIN COUNTY �T <br /> I �j ENVIRONMENTAL HEALTH DEPARTMENT d <br /> �> :, 1868 East Hazelton Avenue, Stockton. CA 95205-6232 <br /> `v...11100 Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> �P <br /> 4�iFOR�.• <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Ser ice Request K: <br /> Onsite Service Technician's Nam#: ICC Service Technician/Installer Exp. a e: ,j Manufacturer Training: <br /> G1Y1�1 �•�-v'�,ri;'?•�� �,,s:•;. � �"`Y�t_ <br /> SERVICEL , SERVI��CE�� <br /> Leak detector SL 1 Spill bucket L9tninimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ © our hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ElOther <br /> ❑ line test programmed <br /> Leak detector _))SG `Spill buA6t ©'minimum 5 gallon <br /> El ❑ mechanical Model: 11 hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor ' <br /> D positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> D fail safe Serial#: minutes <br /> D NA <br /> sensor Secondary containment testing for: <br /> ❑ D positive shutdown Model: UDC(s) Piping <br /> D fail safe Serial#: Sump(s) UST(s) <br /> D NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑positive shutdown Model: <br /> ❑fail safe Serial #: Note. Ptease be aware that 2'containment comperenis are required:o be tested upon <br /> D NA inva!laticn,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring pane! <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 /> re <br /> lwy <br /> t I t J <br /> •t/��f"l'Z?S` C,.h''�i-4' 7Tr.7.y1"v��+ <br /> THIS FACILITY IS-SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S 6URRENT HOURLY RATE. <br /> EHD Inspector: 11 Rec ved By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />