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O.t`4uiN'•.0 <br /> >: +E •.o <br /> SAN JOAQUIN COUNTY <br /> n `,/ENVIRONMENTAL HEALTH DEPARTMEN*../ <br /> 1868 East Hazelton Avenue, Stockton, CA 95205--6232 <br /> P Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> 4�iFORa` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility N me: pecgon Date: <br /> Facility Add ss: i Service Request#: <br /> Onsite Service T chnician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El El mechanical Model: El ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ElCaldwell System ❑ Other <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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ —psi <br /> ❑ fall 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 /> ❑ fall safe Serial#: Note: Please be aware that 2°wntainment components are required to be lest upon <br /> ❑ NA installation,6 months after,end 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) W Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> �jlMlSrer� EeA4 4 0.1w . <br /> M d �t <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By Title: <br /> l <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />