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p4 tN SAN JOAQUIN COUNTY <br /> i <br /> ;%•(,/IRONMENTAL HEALTH DEPARTMENT le <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-62j <br /> ' Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Inspection Date: <br /> Facility Nam ,�"„ � •2 �!y ' <br /> Facility Address: �•I- service bRequest <br /> #: <br /> tee. <br /> ite Service Technician's Name: ICC Se a Te hnicianllnstall Exp.Date: Manufacturer Training: <br /> O <br /> � •'��b f�� �'• � 1/141,1 <br /> SERVICE SERVICE <br /> c Leak detector Spill bucket ❑ minimum 5 gallon <br /> �{ ❑ mechanical Model: "4110 ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 1r► )l[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 /> ❑ ❑ 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 that 2°containment components are required to be 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) EX Other: see below <br /> This UST facility is APPROVED to operate ❑ This LI/ST,,facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe Received By: Title: <br /> MJW "+ c <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />