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AQ�IYkp • <br /> SAN JOAOl11N COUNTY <br /> 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.or0/ehd <br /> �/PORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> aLvQ o hr -6 <br /> Facility Address: Service Request#: <br /> a-0 W. 'fiQ ve aAA o co- , Cit SP-004t4 6'I � <br /> Onsite Service Technician's Name: ICC Service Techniciantinstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial #: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor aAim� Primary piping testing at: <br /> positive shutdown Modelo ❑ psi <br /> ❑fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall 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 2o 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% El 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 /> 30 M `btiOtAd ellkt AlLtkehU��" <br /> vv Q, �� <br /> Loll f <br /> 1A/OIA <br /> THIS FACILITY IS SUBJECT TO REINSPECTION T ANY TIM5 AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect Received Title, <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />