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'•oSAN JOAQUIN COUNTY <br /> .�t ENVIRONMENTAL HEALTH DEPARTMENT <br /> oo: tl <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> -TeA a U� -I- 2ot1 <br /> Facility Address: Service Request#: <br /> Onsite Service-eihnician's Name: ICC Service TechnlcianNnstalle Ex Da e� Manufacturer Training: <br /> cxle� I- <br /> SERVICE SERVICE <br /> Leak detector <br /> LJ mechanical Model: Spill bucket El minimum 5 gallon <br /> ElElEl1 hour hydrostatic LJ Incon TS-STS <br /> ❑ electronic Serial #: L1 Caldwell System F1 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 ro rammed <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> ❑ ❑ fail safe Serial #: psi <br /> El NA minutes <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 /> ❑ fail safe Serial #: Note. Please be aware that 21 containment components are required tc be tested upon <br /> E NA installaticn.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% Ll 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 /> r . <br /> CIQ (. CLi to cx re-h ' Lit . �l <br /> ns aA,e <br /> i l �1 <br /> THIS FACILITY IS SUBJECT TO REIN PEQTION AT AN IME AT END'S CURRENT HOURLY <br /> EHO Ir <br /> isp!c:tor: Rete ed By. Title: <br /> EHD 23-04A UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30112 C)� C9) Q a r t r �� <br />