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p AaV IN �� <br /> SAN JOAQUIN COUNTY <br /> 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 /> 'dli F'o'a" <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> $ a6 -a0 <br /> Facility Address: Service Request#: <br /> C GQW-j()o Ill Q <br /> Onsite Service Technician's Name: I ILC Service Technicianlinstaller Exp. Date: Manufacturer Training: <br /> ium -Q - I$ S�oD - <br /> SERVICE SERVICE <br /> Leak detector _Spill bucket El minimum 5 gallon <br /> El ❑ mechanical Model: El El1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ElCaldwell System ❑ Other <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> Ll El mechanical Model: El [-11 hour hydrostatic El Incon TS-STS <br /> El electronic Serial#: <br /> El line test programmed ElCaldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ ❑ i <br /> ❑ fall safe Serial #: psi <br /> ❑ NA minutes <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 ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA metalla6on,6 months alter.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 /> [I This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> A Oo -b ve r( S1S SW <br /> W - b 0,�,5 IM <br /> 2 er K\P- k r A-66 MiD <br /> n a <br /> -LU rv1 o t�- <br /> ' <br /> r ed r <br /> THIS FACk ITY IS SUBJECT tO Rbf4SPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins c Received By Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />