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pquiry <br /> o c <br /> SAN JOAQUIN COUNTY <br /> ;NVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.siaov.org/ehd <br /> 9��FOR� <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility a e: Inspection Date: 1, <br /> -V-3 <br /> Facility Ad ress: s Sery a Reque #: <br /> t /l ' <br /> C Service Technician's Name: ICC Service Technicianlinstaildr Exp.Date: carr <br /> NA h'i�9 <br /> ,^-- ff 9 <br /> R ICEI 1l <br /> w% k <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ L11 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System 17 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 programmed <br /> sensor <br /> positive shutdown Model p❑ Prmary sl <br /> El fail <br /> at: <br /> El 1-1positive <br /> safe Serial #: <br /> El NA �X minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Surl UST(s) <br /> ❑ NA <br /> sensor ❑ Nesting for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Nate: Please be aware that 20 containment components are required to be tested upon <br /> ❑ NA 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 T stltty is NOT APPROVED to operate <br /> E ` G , <br /> 1)C <br /> Czg I`V` s <br /> ill;mF p II V` Ir f <br /> � -0 �j <br /> THIS FACILITY IS SUBJECT TO REINSPEC ION AT ANY TIOE AT EHD'S CURRENT HOURLY RATE. <br /> EHD ' or: Receiv By: t. Title: <br /> � G <br /> (- <br /> EHD 23-04-/ `` T SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />