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oP4ul,y • <br /> z•�� �o <br /> SAN JOAOUIN COUNTY <br /> N: <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sioov.or0/ehd <br /> 4<iF iRN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectio9 1e: <br /> SRH <br /> Facility Address: Service Re uest#. <br /> 'Tqj E. Dj-- cSRCO Od <br /> Onsite Service Technician's Name: ICC Service Tee nicianinnstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ 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 /> ❑ ❑ fail safe Serial#: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fail 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 /> ❑ NA Note: Please be aware that 2-containment components are required to be tested upon <br /> 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 /> �❑/1 Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> p8 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate. <br /> I't2 1001/7 <br /> All j9arz�"<44. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins actor: R ived By: Title: <br /> f- <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 Qj <br />