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oP4�IN <br /> SAN JOAQUIN COUNTY <br /> ?X ENVIRONMENTAL HEALTH DEPARTMENT <br /> es 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> .. _ p. Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s'goy.org/ehd <br /> UNDER ROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Ins action Date: <br /> IN A06 �l Ci 1 `(�- <br /> Factltty Ass'" 12d Vjjh &2-31 <br /> ��i Service Request k:� <br /> 1*1 <br /> ite <br /> O titre Serrvvi a Technician's Name: ICC Servic echnieia nstaller Exp.Date: Manufacturer T�ing <br /> SERVICE SERVICE <br /> Leak detector <br /> mechanical Model ' Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector _Spill bucket ❑ minimum 5 <br /> ❑ ❑ me hanical Model: P gallon <br /> ❑ ele tronic Serial#: ❑ 111 hour hydrostatic ❑ Incon TS-STS <br /> ❑ 1 ne test proqrammed ❑ Caldwell System ❑ Other <br /> sensor <br /> El ❑ pos five shutdown Model: Primary piping testing at: <br /> ❑fall afe Serial#: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ pos tive 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 /> ❑ fall safe Serial #: <br /> ❑ NA i Note: Please be aware that 20 containmant components are required to be tested upon <br /> installation,6 months after,antl 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) 13 Other: see below <br /> Lx This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> r e C+Y. <br /> I <br /> THIS FA ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT Ell CURRENT HOURLY RATE. <br /> E DI s r Receive Title: h <br /> S 1 PVLG <br /> EHD 3-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />