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Ma, <br /> opgH!N, c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> e: a <br /> N: 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c iP Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> 4<iFOR°' <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> F cilly Name: Inspection Date: <br /> Facility Addr ss: Service Req est <br /> O site Service Technician's Name: ICC Service Tec nician/I taller Exp. Date: ' <br /> GoSE <br /> �, <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 11 minimum 5 gallon <br /> ❑ El mechanical Model: F-1 <br /> El1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: El Caldwell System El Other <br /> El line test programmed <br /> Leak detector Spill bucket 71 minimum 5 gallon <br /> ❑ El mechanical Model: ❑ El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: El Caldwell System El Other <br /> ❑ line test programmed <br /> sensor Primarytesting at: <br /> ❑ ❑ positive shutdown Model: psi <br /> ❑fad safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fail safe Serial#: Surl UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#I Note: Please be aware that 2r containment components are required to be tested upon <br /> [INA installation,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 -TtSis S cl l is NOT APPROVED to operate <br /> +7) lnnlM-uffl-fz; Vol <br /> r <br /> V� 1.e- <br /> ` L' vW <br /> VW- <br /> THIS FACILITY IS SUBJECT TO REINSP CTION A ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins ec r: �. Rec 'ved8'. 1 Title71 ij : <br /> EHD 23-04 4(J SERVICE REQUEST SPECTION REPORT <br /> Rev 4/30/12 <br /> u <br />