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i <br /> �pUtty I <br /> ""'�� 0 SAN JOAQUIN COUNTY <br /> y' ENVIRONMENTAL HEALTH DEPARTMENT I <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> _ Telephone:(209) 468-3420 Fax: (249) 468-3433 Web:www,si•ocovv.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> o % � ?)-I <br /> Facility Address:'- Service Request#: <br /> Onsite Service Technician's Name: IC vice T chniciantinstaller Exp.Date: Manufacturer Training: �)-tCLIS® <br /> k <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> F1 mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System F1 Other <br /> El line test programmed <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ 111 hour hydrostatic 1-1InconTS-STS <br /> 11 line test programmed <br /> F1 Caldwell System 11 Other <br /> sensor Primary piping testing at: <br /> Elpositive shutdown Model: <br /> ❑ fail safe Serial #: psi <br /> ❑ NA t ' minutes E <br /> sensor Secondary containment testing for: <br /> ❑ Ll t- 9^Y60 rVIAV, <br /> positive shutdown Model: UDC(s) ping <br /> ❑fail safe Serial #: , Sump(S) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ElLlpositive shutdown Model: <br /> ❑ fail safe Serial #: <br /> Note: Please be aware that 21 containment components are requvrad to be tested upon <br /> Ll NA Ins tMakin,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% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate Thi UST facility is NOT APPROVED to operate <br /> OD Y+ , <br /> Q (Aav C VNA '-, <br /> 5 _ <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspe Rece y; Title <br /> RHD 23-04 <br /> Rev 4130/12 UST SERVICE REQUEST INSPECTION REPORT <br />