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lry, <br /> �.i�' •� SAN JOAOUIN COUNTY l <br /> ENVIRONMENTAL HEALTH DEPARTMENT I{1 EE I Y�//E D <br /> `I1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> t- wv <br /> ° Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.slgOy.Orq/ehd jUN 08 2015 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSP��kT <br /> "„1CMAOTCall <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request It: <br /> Onsite Service Technician's Name: ICC Sel Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑mechanical Model: Incon <br /> ❑ ❑electronic Serial#: El 1 hour hydrostatic 71TS-STS <br /> ❑ Caldwell System ❑ Other <br /> El line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model. ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor TO -- <br /> ary 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 /> ❑fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> El ❑ positive shutdown Model: <br /> ❑fall safe Serial#: N e: P eeae re a rare dmt 1°m anma i mrtgonarrb are tenured lu be lemed upon <br /> ❑ NA a lelbn 6 monms alar,and ee W momes Naraaller <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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector Received By. Title <br /> EHD 23.04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 <br />