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SAN JOAQUIN COUNTY <br /> Q' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> P . Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sioov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> C Zn e . A a a•0I't <br /> Facility Address: Service Request- <br /> -3 s a e go 5'fZ©C) 68&11--? <br /> Onsite Service Technician's Name: ICC Service TechnicianAnstaller Exp.Date: Manufacturer Tire'<�m dolt giz� /i vR 4j <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El ❑ mechanical Model: El ❑ 1 hour hydrostatic 11 Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System Ll Other <br /> El line test programmed <br /> Leak detector Spill bucket 1-1minimum5 gallon <br /> El El mechanical Model:❑ electronic Serial #: El El1 hour hydrostatic ElIncon TS-STS <br /> El Caldwell System ❑ Other <br /> ❑ line test ro rammed <br /> o sensor <br /> cy ❑ positive shutdown Model: Primary piping testing at: <br /> jY{ <br /> El fail safe Serial #: I of g i 5xj ❑ psi <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 <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 26 containment components are required to be tested upon <br /> ❑ NA installation,6 months atter,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 ❑ This UST facility is NOT APPROVED to operate <br /> -t( I <br /> 1 <br /> THIS FACILITY IS SUWEFTTO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In ctor Received By: f Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/1 <br />