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P0.�IN, `,/ SAN JOAQUIN COUNTY <br /> _: -tea' , '••y <br /> � ..� ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> . _ Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siaov.oralehd <br /> ��FDFN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> S t-7LJ3 <br /> Fa tty AreWS: �� Se ce #: <br /> 14 <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <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 /> ❑ line 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 Prupary piping testing at: <br /> El positive shutdown Model: �psi <br /> ❑ fall safe Serial#: minutes <br /> ❑ NA <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 ❑ Nesting for the above components are next due by: <br /> El ❑ positive shutdown Model: <br /> ❑fall safe Serial#: Note: Please be aware that 2°containment components are required to bs tested upon <br /> ❑ 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) ❑L(jOther: see below <br /> El This UST facility is APPROVED to operate ? 1J UiST#ariW is NOT APPROVED to operate <br /> (W; - <br /> L- -16P6lip,otafimtwQWh - <br /> r <br /> `n. t <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In clot: I Recei ed By: T <br /> EHD 23-04 0 UST SERVICE REQUEST INS ECTION REPORT <br /> Rev 4130112 <br />