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oPQ_uIry c <br /> SAN JoAaUIN COUNTY <br /> q' ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s'gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Name: Inspection Date: <br /> Facility Address: -{� . C Service Request#: <br /> Onsite Service Technician's Name: [cc Service Techn ian/lnstal E��date: Manufacturer Trainin <br /> �'- <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket Llminimum 5 gallon <br /> ❑ ❑ ❑ 1 hour hydrostatic LlIncon TS-STS <br /> electronic Serial #: F1 Caldwell System Ll Other <br /> ❑ line test programmed <br /> Leak detector � <br /> Spill bucket ❑ minimum 5 gallon <br /> Ll El Madel: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System Ll Other <br /> r <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> LiElpositive shutdown Model � <br /> ❑ fail safe Serial #: psi <br /> El NA C64D minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model UDC(s) 6iodj,< I Z0JPiping <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 to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter, i <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 U�$T�facility is NOT APPROVED to operate <br /> y&�4 40 P& VQ_ 5Ds <br /> CQcUej&eL I"y'riw 02 t <br /> I <br /> pat, ep In <br /> L <br /> a <br /> 1 a-t, ( Gu <br /> 41uC 40 E rri e Ctllsk-l'i oA-4 n <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspe o Received By: <br /> Fit <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REP:RT <br /> Rev 4130112 <br /> I <br />