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o�aaln. • <br /> r;• r-«.—. ;Z SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> a` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s4gov.org/ehd <br /> 9/%FORN� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> /z 2 is <br /> Facility Address: Service Request#: <br /> 0�5P-5 S'fV -SR20 -7-f3< lvD <br /> Onsite Service Technician' Name: ICC Service Technician/Installer Exp.Date: Manufacturer Train' g: <br /> N 1 & b � ' --'ole 7 I <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ El mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: y <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ El mechanical Model: ❑ <br /> ❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> E-10 positive shutdown Model: psi <br /> ❑fall safe Serial#: <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ <br /> El positive shutdown Model: UDC(s) Piping <br /> ❑fall safe Serial#: Sump(s) <br /> ❑ NA UST(s) <br /> � <br /> sensor /—` Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: 111/12Ito <br /> El fail safe Serial #: —' <br /> ❑ NA Note: Please be aware that 2°containment components are required to be tested upon <br /> 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 LG letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> �r <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: ,. / Title: <br /> EHD 23-04 <br /> Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT <br />