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SAN JOAQUIN COUNTY <br /> �.•�.k •.off <br /> Z' r—cr •Z <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sogov.org/ehd <br /> �4�ikoRN�p <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name; � � Inscon�ate; <br /> WhaLl VI 1 1 <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/lnstaller E p.Date:n Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: 11Cafdweli System C] Other <br /> 71 line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> Li ❑ electronic Serial: El 1 hour hydrostatic LlIncon TS-STS <br /> LJ line test ro rammed Ll Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Madel: Primary piping testing at: <br /> El psi <br /> ❑fail safe Serial #: <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: �w 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 2°containment components are required to he tested upon <br /> ❑ NA 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 /> Wo 40 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT AIjY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E D nspe ftor. Received B - Title: - <br /> n . _ <br /> LA <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130/12 <br />