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o,�qu l ty•.o <br /> SAN JOAQUIN COUNTY <br /> W: { NVIRONMENTAL HEALTH DEPARTMENT <br /> I- 9868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.s[gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> {►h� CUMrnInv�IC� �5 r q— 13 <br /> Facility Ad ress: Service Request#: <br /> 315o)-7 �►�- ��� Avg �� �'fz����� � <br /> Onsite Service Tec ician's Name: I Service Technicianlinstaller Exp.Date: Manufacturer Training: r <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: 1 Spill bucket ,M�inimum 5 gallon <br /> ❑ ❑ 1 hour hydrostatic [�Incon TS-STS <br /> ❑ electronic Serial#: � Y <br /> ❑ line test pro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> D 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 /> El <br /> F-1 fail safe Serial #: ❑ psi <br /> D NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> El fail 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#: <br /> F-1 NA Note, Please be aware that 2°containment components are required to be tested upon <br /> Installation,6 months after,and every°..6 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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins or: Receiv y: Title: <br /> . � -- <br /> EHp 23 <br /> Rev 4/30192 UST SERVICE REQUEST INSPECTION REPORT <br />