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P°StN- <br /> ?-•-�'•- SAN JOAQUIN COUNTY <br /> c --cr- � ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> V. Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.siaov.org/ehd <br /> a<,FaR <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> e o ala <br /> Facility Address: Service Request#: <br /> G 4 <br /> Onsite Service Technician's Name: ICC Service Technici n11nstaller Exp.Date: Manufacturer Training: <br /> ow -f6 6?/a0 1,2019 vn <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> l)Kmechanical Model: �.� <br /> ❑ ❑ electronic Serial# ❑ ❑ 1 hour hydrostatic ❑ Incon TS STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> 11 ❑❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ElElpositive 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 /> E] ❑ positive shutdown Model: <br /> ❑ fad safe Serial #: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA imizllabon,6 months akar,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 LIS letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> %7Vksl 72kr <br /> LClrso �? rv� <br /> b i w <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIM AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe Receive Tit <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 <br />