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oAQurN c <br /> -�rEE <br /> ,2.• _,_�. .�� SAN JOAQUIN COUNTY <br /> `e ai ENVIRONMENTAL HEALTH DEPARTMENT <br /> ,. � j 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 1` Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> �a ..::..:.•;P; <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Name: Inspection Date: <br /> Facility Address: n Service Request#:`�1 rl ��`(�'�, � `� l leu-11,�Q C� <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exo_nate: Manufacturer Training: <br /> n k I R 1\lOv/ - I- - cl u <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 Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El mechanical Model: 1:1 ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System 11 Other <br /> El line test programmed <br /> _sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: C-,:5 a,4V,1 —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 21 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 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 -A z, S <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> Vill Ct�i ICL- <br /> G D I C', 1.Aq <br /> (-k4 <br /> THIS FACILITY IS SUBJECT O REINSPEC N AT ANY TIME AT EHD'S CURRENT HOU LY RAT . <br /> F <br /> s tor: Rece ed / Titl <br /> i �/ rf[`' <br /> El 23-04 l (�� `) UST'SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 l �/ <br />