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-L <br /> 'Ci \ <br /> SAN JOAQUIN COUNTY <br /> Q. ENVIRONMENTAL HEALTH DEPARTMENT <br /> N.i i 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 /> �*xv CLQ 65/2�/I 8' <br /> Facility Address: Service Request#: <br /> )q q S 11/ll lr� 1CP oe--ka Zzz <br /> Onsite Service Technician's Name: ICC Service Technician nstaller xp.Date: Manufacturer Training: <br /> mqyt A t-2 q 'Xuvs Illb/1-1 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial:: El El hour hydrostatic El Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> sensor <br /> ❑ <br /> El positive shutdown Model: ❑ Primary piping testing at: <br /> I psi <br /> ❑ 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 /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 9590 ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Ml Other: see below v— S <br /> ❑ This UST facility is APPROVED to operate " This UST facility is NOT APPROVED to operate <br /> I "e W1 4fdioA at <br /> 11J7 �1'/h <br /> i r <br /> THIS FACILI SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> D Inspec Re i d 4Tj <br /> r <br /> Q It ol 00 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />