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R4�Iry. <br /> �o. E.co SAN JOAQUIN COUNTY <br /> a y ENVIRONMENTAL HEALTH DEPARTMENT V <br /> �$ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.sfoov.org/ehd <br /> dGjFOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 6Z*110i 6-0r-U'3 <br /> Facility Address: _ Service Request#: <br /> 0fe6M <br /> site rvwe Technician's Name: ICC S&vice Technician/Installer Exp.Date: Manufacturer Training: <br /> bLpan 3 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ fine 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 Pr. imary piping testing at: F�" <br /> El positive shutdown Model: . jr psi <br /> ❑fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ 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 /> ❑ fall safe Serial#: NO. Please t s aware that 2°containment components are required to b tested upon <br /> ❑ NA instailabon,a 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%�--d ❑ I Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate T.Nis UST-faeifity is NOT APPROVED to operate <br /> ' 4 6A7A K.T. b99�mAWj <br /> it U <br /> r Fe <br /> na <br /> THIS FACILITY IS SUBJECT TO RCIPISPECTION AT AN TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH ctor: Rec i d By: Title: <br /> EHD 23-04 ( UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30112 <br />