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Pqu1N 1 <br /> SAN JOAQUIN COUNTY <br /> --T\ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.s*gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> 141© "ZLA- skru± jwc � - Sn•no'-�-6 0()-j- <br /> nsite Service Technician's Name: ICC Service T chnician/Installer Exp. Date: Manufacturer Training: vR-- Q— <br /> �,�N <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ El electronic Serial#: ❑ 1 hour hydrostatic )ncon TS-STS <br /> El test ro rammed ❑ Caldwell System Otherdfal <br /> 11 <br /> Leak detector a <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ 1 hour hydrostatic Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System Other l <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> El NA minutes <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 /> ❑ NA installation.6 months after,and every 36 morths 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 X This UST facility is NOT APPROVED to operate <br /> WA Q h OST- tC2Q004N�0 f <br /> ll�l L; cum w UQ - eUtQ-8 . VCLW i)rn C oc.` <br /> V o ►w i S wf Ci #i s q I S- L e- <br /> N XXoQkWES a1 Q � L <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY T%AE AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insctor: Recei By: Title: <br /> EHD 23-04 lJ✓Vy V UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />