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oP4ufN c <br /> SAN JOAOUIN COUNTY 41 <br /> c-- ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> p 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 /> a8 z a -?)- ao V+ <br /> Facility Address: I - Service Request#: <br /> � W, 2 lC1GQ CA cc-46v,=3 <br /> OnsiJq Servi'-�a Technician's Name: CC Service Technician/installer Exp.Date: Manufacturer Training: <br /> cX � S • CaC <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> E] ❑ mechanical Model:❑ electronic Serial El ElY <br /> 1 hour hydrostatic ❑ Incon TS-STS <br /> #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> CT! Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: y <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ fall safe Serial#: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: I <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 #: <br /> ❑ NA Note: Please be aware that 2°containment components are required to be tested upon <br /> 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 /> IA,' 9( ije r L&C clo eeApfQL� <br /> f ofiOAD <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO,�r,AT A IME AT EHD'S CURRENT HOURLY RATE, <br /> EHD Inspector Receiv <br /> Y: Title: <br /> EHD 23-04UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/10/12 <br />