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o^Agt7_ <br /> ''•;. `,''•.p1 v SAN JOAQUIN COUNTY 11/ <br /> ,r'r•'� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Iaik V, <br /> Facility Address: / Service Request#: 81( <br /> �klron c_Z_ZYY7 19 <br /> Onsite Service Technician's Name: C service echnician/Installer Exp. Date: Manufacturer Training: <br /> rt t�dr d h.��;t� ti otg <br /> SERVICE SERVICE <br /> _Leak detector <br /> ❑ ❑ mechanical Model: l Spill bucket A minimum 5 gallon <br /> ❑ electronic Serial#: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: _Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> F-1 ❑ fail safe Serial ti ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> F1 El positive shutdown Model: UDC(s) Piping <br /> El safe Serial#: <br /> ❑ NA Sump(s) UST(s) <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: <br /> Note: Please be aware that 2°containment components are required to be tested upon <br /> 1-1 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 /> no eri 11 'xmurm <br /> \ �-U StCI} re 1 Jctb1l <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Recei By: Title;, 11 <br /> iv <br /> EHU 23-04 UST SERVICE REQUEST INS TION REPORT <br /> Rev 4/30/12 <br />