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�••.,yFa,•,'� � SAN JOAQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> ur 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ". Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.siqov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: �✓C7 Inspection Date: <br /> �p 5 .213- 15 <br /> Facili Address: Service Request III: <br /> Onyite Servic Technician's Name: ICC Service Technici A Ile p. ate: Mpnufacturer Trainjrtg;•,�I ' <br /> q N <br /> SERVICE SERVICE <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 /> 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 /> ❑fail safe Serial#: minutes <br /> ❑ NA <br /> sensor co dary containment tes 'n for: t t!x S�lo <br /> ❑ ❑ positive shutdown Model: UDC(s) uGl w Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing f r the 4bove components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note Plea4 be aware tL P containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and a ery 36 months Neraanar <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 /> G�esu(9 43 aveLab 0:4,01 <br /> n <br /> uVAt, / 1 <br /> W r wldl�l l <br /> 'wr- <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH Received Title: <br /> Y <br /> EHD 23-04 U UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />