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A V 1Iy <br /> 1�11?q'-�t' 9� �"� SAN JOAQUIN COUNTY f <br /> � ENVIRONMENTAL HEALTH DEPARTMENT <br /> y:� ' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i�5` Telephone:(209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> 'P<lFoa�''� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> CX ; -aa-a.o� <br /> Facility dress: Service Request* <br /> S_ et, Q-a m a-19 ts <br /> Onsite Service Technician's Name: ICC Service Technici nstaller Exp.Date: Manufacturer Training: <br /> c2rgr �4D7- -� ' vim- .J <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: <br /> El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> El positive shutdown Model: ❑ Primary S piping testing at: <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 ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note Please be aware that 20 containment components are required to be tested upon <br /> ❑ NA installation,s months after,and every W 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 /> o") 1 PYuv'k kao wsic�c ot_Le 01\ <br /> r Ir <br /> v9C` rq"cn e <br /> 1 W IA 0- <br /> to efto- <br /> . 1 <br /> k d s1 � 1 �. e2 <br /> THIS FACILITY IS SUBJECT TO REINSPEC Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins a rRe Title: <br /> EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />