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SAN JOAQUIN COUNTY .i <br /> 2' ENVIRONMENTAL HEALTH DEPARTMENT <br /> �•� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �. P. Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> 4�/FORS` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> nLt4T 1) <br /> Facility Add ess: Service Reque t#: ll�� <br /> r W2 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufactu Tr (aG( C <br /> � - <br /> SERVICE SERVICE <br /> P_l3LZL Leak detector `- S Spill bucket El minimum 5 gallon <br /> 'Qmechanical Model �_ �� D 7f—M ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial # ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El ❑ mechanical Model: El ❑ 1 hour hydrostatic L1 Incon TS-STS <br /> E) line test programmed❑ electronic Serial #: ElCaldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑fail safe Serial #: <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: 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 tm aware that 2°containment components are requiretl to ce asmat 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 /> El Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> IAI This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> m0goal <br /> YLLA-b aid( <br /> IQTArIU <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins p or Receive Title: <br /> (o z. <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />