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OA��f <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> f Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.orq/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> s-f C) t 2 0 lh <br /> Facility Address: Servic Requ st#: <br /> 0 kV r r- '� I e J 9 <br /> Onsite Service Technician's Name: ICC Service Technicianllnstal Exp. Date: Manufacturer Training: <br /> Javn,l B it rk e_ (2 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ ❑ mechanicai Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ fail safe Serial #: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> 11positive shutdown Model: UDC(s) Piping <br /> ❑ faii safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> Llpositive shutdown Model: <br /> ❑ fail safe Serial#: <br /> ❑ NA Note. Please he aware that 2"containment components are required to be tested upon <br /> 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) Other: see below <br /> 14 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> l y-y � r <br /> 1 7 v 1 ►1 6' > >c� C , <br /> k7 d <br /> r,1 S U f Y J .c' 1 gf <br /> rTy 9 , C� sir r e Vl ray i �I S <br /> S" a t/ J ofi e ,,,,,i <br /> THIS FACILITY S SUBJECT TO REINSPECTION AT ANY T E AT EHD'S CURRENT HOURLY RATE, <br /> EHD Ins ector: Received H <br /> �1 Y: c ZTitle-: <br /> 1► r- e cru C h n,f S n lq <br /> EHD 23-04 <br /> Rev 4130112 <br /> UST SERVICE REQUEST INSPECTION REPORT <br />