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Pqutry' SAN JOAQUIN COUNTY • <br /> QTS y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.oro/ehd <br /> �4CiFORa`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> My Mih 't M I I / 1 7 / Zol <br /> Facility Address: Service Request a: <br /> x-56 vJ ; Ism s40C,k+OYt S2 0 0 TO o <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> �r�s P�aw�s <br /> -ZjIzft0I5'-L M I l ft it 7- &1 <br /> SERVICE SERVICE <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> mechanical Model: v M ) ❑ C, 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial# Q ❑ Caldwell System ❑ Other <br /> ❑ line test programmed if <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 /> ❑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: Please be aware Mat 2c containment components are requmad to be tested upon <br /> El NA installation.6 months after,and ovary 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 /> bier �� � � o � <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In ecto . 'V ReceivedTitle: <br /> EHD 23-4/ UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />