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oP4u I.y... <br /> x'�E •.o SAN JOAQUIN COUNTY <br /> x• Z� ENVIRONMENTAL HEALTH DEPARTMENi--� <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> ��tFORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fact ty Na e: Ins action Date: <br /> -10 c 6C 401 7 <br /> Fac dress: S rvice Request#: <br /> OnService Tec nici n's Name: ICC Service Tec icianlinstaller Exp.Date: Manufacturer6/ <br /> s a Training: <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 /> ❑ ❑ 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 /> El ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fall 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: Phase be aware that 20 mnwruneM components are required to t,e tested upon <br /> ❑ NA nstallation,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 y <br /> ❑ This UST facility is APPROVED to operate This�UST�� 1s NOT APPROVED to operate <br /> Nc5k IUY N� t(n IN / p,, 11.1 <br /> YrINrN'n " (/ Ie <br /> THIS FACILITY 18 SUBJECT TO REINSPETION AT ANYTIME EHD'S CURRENT HOURLY RATE. <br /> Aft <br /> EHD Inspector a ved Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />