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SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT 20.S ,3� <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:WWW.sigov.org/ehd <br /> ••;FpRN"" <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 0)QA/ — r;),I - , I Cl <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/nstaller Exp. Date: Manufacturer Training: ( () <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> 11 electronic Serial #: El hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> [I Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ - ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> pi <br /> El ❑ fail safe Serial #: ❑ minutes <br /> ❑ NA <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 2°containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> q� g Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> Drop tube with mechanical overfill at 950, ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Other: see below r' <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT AP ROED to operate <br /> 40 V r e/y ' 4i tLAD <br /> V Q;V 14 ( 1 1 T "e L <br /> 5 c I (mss ab C <br /> -3UA {, �S <br /> J@.lt Cela V\ -�Xtc k,11 S 5O +'s <br /> I� bbl �i <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EH 'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receiv i3y: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />