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�U IN <br /> ?� 0��, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> w. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 1 Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.siclov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility <br /> /Name: <br /> f.� /� Inspection Date: C <br /> ev <br /> Facility Address: Service Request#: <br /> �LA q 0 -S t (.C6 *a;Il7 iii ��`CxIe 12f 0 C;--- a- <br /> Onsite Service Technician's Name: ICC Service Tech lcian/Installer Exp.Date: Manufacturer Training: <br /> Y1uz, �D32 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket 1:1 minimum 5 gallon <br /> ❑ ❑ El❑ electronic Serial #: 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial #: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> sensor <br /> positive shutdown Model: ❑ Primary testing at: <br /> El Elsi <br /> Elfail 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 20 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 950/0 ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) rA70ther: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> io <br /> CUP <br /> A i AA Q V�QiI�6 n , r �) O— <br /> r <br /> s� �-- <br /> �� ' V-1M V C� l <br /> THIS FACILITY IS SUBJECT TO EINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: �^ Receiv By: f—� _-- Title:�L D -�` <br /> 1"` , <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4;30/12 <br />