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p44�fN <br /> �q•�"•'• SAN JOAQUIN COUNTY <br /> r�a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Svo W. (Ott -)vo (,9•& SV 0Dq 6'7 6�F <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> �1hlo <br /> SERVICE SERVICE <br /> Leak detector n , .V 1 ccs <br /> mechanical Model: _Spill bucket ❑ minimum 5 gallon <br /> V felectronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> _Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model:❑ p❑ fall safe Serial#: El <br /> ❑ NA minutes <br /> — <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 2°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 ❑ This UST facility is NOT APPROVED to operate <br /> Inyi�e - Cidi vie Uivie k&L <br /> rp bikVUT- L <br /> YUO <br /> NIA s - �a t <br /> 'tks o ti S�C1� < <br /> a <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI E AT EHD'S CURRENT HOURLY RATE. <br /> EHD ftlInspector Rece B Title: <br /> - Q.�f�. �� TSfrn lecAl <br /> EHD 23-04 UST SERVICER UEST INSPECTION REPORT <br /> Rev 4/30/12 <br />