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i <br /> SAN JOAQUIN COUNTY <br /> :Z <br /> IV: ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sjgov.org/ehd <br /> ��lFOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspect'an Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Teclinicianl stalle Exp.Date: Manufacturer TragZg ;3_ <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 erogrammed <br /> Leak detector <br /> F1 mechanical Model: 11ElSpill bucket 11 minimum 5 gallon <br /> El ❑ 1 hour hydrostatic Incon TS-STS <br /> F1 electronic Serial: <br /> 171 line test programmed <br /> ❑ Caldwell System El Other <br /> sensorP � lu� `' M.. <br /> Z <br /> ri y p �'ariping testing at: q <br /> ❑ ❑ positive shutdown Model: E psi t_ r 46�f y� <br /> ❑ fail safe Serial #: <br /> ❑ 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 -s—.v E'v—1 ,h) <br /> sensor Testing for he above compondnts are next due by: <br /> ❑ ❑ positive shutdown Model: 0 <br /> 11 fail safe Serial #: Note: Plea eTkMrra^t#�at 2 contalnment components are required to be tested upon <br /> 11 NA installation, months ofi ,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 /> ❑ This UST facility is APPROVED to operate Xr This UST facility is NOT APPROVED to operate <br /> qn <br /> r� r lt` 7 f` r�, � tl�- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EH spector: received 13' Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />